Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors

Perceived feasibility, acceptability and impact of the family involvement intervention for severe mental illness: a qualitative study in Masaka - Uganda

BACKGROUND

The burden of severe mental illness is high in low-resource settings like Uganda. But most affected people are not treated due to inadequacy of sectoral funding and trained mental health professionals. Medication has hitherto been the main method of treatment for severe mental illness worldwide. However, there is a growing realization that the use of community-based resource-oriented interventions like the family involvement are more effective and suitable for under-resourced settings. But there is a paucity of information about its applicability in Uganda.

METHODS

We based the intervention at the mental health unit of Masaka Regional Referral Hospital, involving 30 patients with SMI, 60 family members and friends, and 6 mental health clinicians. It was delivered through regular monthly meetings of 5 patients, 10 caretakers, and 2 clinicians each, for six months. A purposive sample of 15 patients, 15 caretakers, and 6 clinicians participated in this qualitative evaluation study after 6 months. Data was collected using in-depth interviews. Atlas.Ti (version 7.0.82) computer software was used in data analysis. Both priori and grounded codes were used to code data.

RESULTS

We evaluated perceived feasibility, acceptability and impact of the intervention in the Ugandan context. The findings were largely positive. Feasibility was mainly driven by: the training of group facilitators, field support and supervision, prior relationship between participants, and scheduling and timing of meetings. Acceptability was supported by: anticipation of knowledge about mental illness, process and content of meetings, safety of meeting environment, and choice of participants and venue. Impact was majorly in domains of: knowledge about mental illness, psychosocial aspects of mental illness, networking and bonding, and patients' quality of life. The success of the intervention would further be enhanced by its decentralization and homogenized composition of groups.

CONCLUSIONS

The intervention promises to spur improvement in the following main aspects of mental health services: accessibility since the meeting environment is more neutral and friendlier than the clinical setup; knowledge of mental illness; recognition of the important role of the family in management of mental illness; adoption of holistic approaches to mental illness; and quality of life of patients.

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.

Predictors of family-focused practices among mental health workers in Quebec

Context

Engaging family members in the ongoing care of individuals with mental illness is a practice known to bolster the client's recovery journey and enhance the overall wellbeing of both children and families involved. Despite its potential benefits, there remains a dearth of understanding surrounding the implementation of family-focused practices (FFP) by mental health professionals serving adults, as well as the factors that could either promote or hinder such practices. This knowledge gap is particularly pronounced within North American settings.

Goal

The goal of this study was to identify potential hindering and enabling factors of FFP used in adult mental health services.

Methods

A sample of 512 professionals working with adult mental health clients, from all regions of Quebec, Canada, with a variety of disciplinary backgrounds and working in different work settings, completed the Family Focused Mental Health Practice Questionnaire (FFMHPQ). Multinominal logistic regression analysis was performed to assess the impact of several factors - organizational, professional, and personal - on the degree of family-based practices of mental health workers.

Results and discussion

Findings of this study show that the strongest predictors for the adoption of higher FFP levels among adult mental health professionals in Quebec, are being employed on a full-time basis, perceiving a higher level of skills, knowledge, and confidence toward FFP, and having a supportive workplace environment. Results underscore the need to address both organizational and worker-related aspects to effectively promote better FFP in mental health services.

The impact of early intervention psychosis services on hospitalisation experiences: a qualitative study with young people and their carers

BACKGROUND

While a core aim of early intervention psychosis services (EIPS) is to prevent hospitalisation, many with a first episode of psychosis (FEP) will require inpatient care. We explored young people's (YP) and their carers' hospitalisation experiences prior to and during EIPS engagement and how factors across these services influenced these experiences.

METHODS

Using purposive sampling, we recruited twenty-seven YP, all of whom had been involved with the hospital system at some stage, and twelve support persons (parents and partners of YP) from state and federally funded EIPS in Australia with different models of care and integration with secondary mental health care. Audio-recorded interviews were conducted face-to-face or via phone. A diverse research team (including lived experience, clinician, and academic researchers) used an inductive thematic analysis process.

RESULTS

Four key themes were identified as influential in shaping participant's hospital experiences and provide ideas for an approach to care that is improved by the effective coordination of that care, and includes this care being delivered in a trauma informed manner: (1) A two-way street: EIPS affected how participants experienced hospitalisation, and vice versa; (2) It's about people: the quality and continuity of relationships participants had with staff, in hospital and at their EIPS, was central to their experience; (3) A gradual feeling of agency: participants viewed EIPS as both reducing involuntary care and supporting their self-management; and (4) Care coordination as navigation for the healthcare system: great when it works; frustrating when it breaks down.

CONCLUSIONS

Hospitalisation was viewed as a stressful and frequently traumatic event, but a approach to care founded on trust, transparency, and collaboration that is trauma-informed ameliorated this negative experience. Consistent EIPS care coordination was reported as essential in assisting YP and carers navigate the hospital system; conversely, discontinuity in EIPS staff and lack of integration of EIPS with hospital care undermined the positive impact of the EIPS care coordinator during hospitalisation. Care coordinator involvement as a facilitator, information provider, and collaborator in inpatient treatment decisions may improve the usefulness and meaningfulness of hospital interventions.

Structural barriers to help-seeking in first-episode psychosis: A systematic review and thematic synthesis

AIM

Access to timely treatment is key to early intervention in psychosis. Despite this, barriers to treatment exist. In this review, we aimed to understand the structural barriers that patients and caregivers face in help-seeking for first-episode psychosis, and the recommendations provided to address these.

METHODS

We conducted a systematic review (PROSPERO: CRD42021274609) of qualitative studies reporting structural barriers to help-seeking from the patient or caregiver perspective. Searches were performed in September 2023, restricted to studies published from 2001. Study quality was appraised using Critical Appraisal Skills Programme. Data were analysed using thematic synthesis.

RESULTS

Nineteen papers from 11 countries were included. Across all papers, participants reported experiencing structural barriers to receiving healthcare. For many patients and caregivers, the process of accessing healthcare is complex. Access requires knowledge and resources from parents, caregivers and healthcare providers, yet too often there is a misalignment between patients' needs and service resources. Expertise amongst healthcare providers vary and some patients and caregivers experience negative encounters in healthcare. Patients highlighted earlier caregiver involvement and greater peer support as potential routes for improvement.

CONCLUSION

Patients and caregivers face multiple structural barriers, with legislative practices that discourage family involvement, and healthcare and transport costs found to be particularly problematic. Understanding these barriers can facilitate the co-design of both new and existing services to provide easier access for patients and caregivers. Further research is needed focusing not only on the perspectives of patients and caregivers who have accessed professional help but also crucially on those who have not.

Needs and Problems of the Caregivers of Psychiatric Patients With Violent Behaviours

BACKGROUND

Violent behaviour exhibited by psychiatric patients is a major problem faced by their family members. Agitated violent patients constitute a part of all emergency psychiatry treatment, and family members carry out most of the care for the mentally ill. Caring for the mentally ill is a burden for the caregivers, and they face difficulties and problems that affect their health and well-being.

AIM

This study aimed to assess the needs and problems of the caregivers of psychiatric patients with violent behaviour.

METHOD

This study was conducted at Mary Lott Lyles Hospital, Andhra Pradesh, India. Fifty caregivers of patients with violent behaviour were assessed concerning their needs and problems, which were explored using an open-ended questionnaire, and responses were documented and voice-recorded. Qualitative and quantitative analyses were done.

RESULTS

 Caregivers of psychiatric patients exhibiting violent behaviour face pressing needs and formidable challenges. They urgently require prompt treatment, detailed explanations from healthcare professionals and hope for their loved ones' full recovery. However, they grapple with managing the unpredictable and aggressive behaviour of patients, transportation difficulties and the pervasive stigma of mental illness. Economic crises further exacerbate their struggles, making it challenging to access necessary care and support for their relatives.

CONCLUSION

 Despite the challenges encountered in handling violent behaviour, caregivers consistently ensured that patients received emergency treatment and ongoing care. They stressed the importance of healthcare professionals understanding their needs and those of the patients. These results highlight the necessity of addressing the comprehensive requirements of both patients and caregivers when dealing with violent behaviour in psychiatric settings.

Shortcomings of services for persons with severe and persistent mental health challenges: a qualitative study of service users and family carers

Introduction

The opinions of service users and carers are crucial to identifying ways to innovate and implement system change. This study aims to explore the views and experiences of service users and carerson the services they have used for their mental health challenges and their suggestions for service reform.

Methods

Twenty participants (15 carers and 5 service users) were interviewed for the study.

Results

Eight categories emerged from the data. They were: Several gaps in the system, Barriers to accessing services, Services are not fit for purpose, Services operate in isolation, System is not person focused, Service users and carers are treated poorly, Services are overloaded and under resourced and Recommendations for service reform. Respondents reported that a persistent lack of funding and resources for mental health services was a main cause of these shortcomings. Respondents also noted that innovations were needed to re-orient services to enable continuity of care, and training of mental health professionals was needed for a better understanding of the needs of service users and their carers.

Discussion

Additional research is needed with larger and more diverse samples to further explore these findings.

Family Psycho-Social Involvement Intervention for severe mental illness in Uganda

Background

Treatment rates for severe mental illness (SMI) are low in low- and middle-income countries because of limited resources. Enlisting family support could be effective and low cost in improving patient outcomes.

Aim

The article assess the feasibility, acceptability and estimates of efficacy of Family Psychosocial Involvement Intervention (FAPII) for patients with SMI.

Setting

Masaka Regional Referral Hospital and Mityana District Hospital in Uganda.

Methods

This was a controlled pilot study with two sites randomly assigned as intervention and control. Thirty patients each with one or two family members and six mental health professionals were recruited at the intervention site. Five patients, their family members and two mental health professionals met monthly for 6 months to discuss pre-agreed mental health topics. Patient outcomes were assessed at baseline, 6- and 12-months and analysed using paired t-tests. The trial was prospectively registered (ISRCTN25146122).

Results

At 6 and 12 months, there was significant improvement in the QoL in the intervention group compared to the control (p = 0.001). There was significant symptom reduction in the intervention group at 6 and 12 months (p < 0.001). Family Psychosocial Involvement Intervention affected better treatment adherence at 6 and 12 months (p = 0.035 and p < 0.001, respectively) compared to the control arm.

Conclusion

Family Psychosocial Involvement Intervention improved QoL, medication adherence, reduced stigma and symptoms among patients with SMI. The authors recommend involving families in the care of patients with SMI in Uganda, with FAPII employing culturally sensitive psychotherapy.

Contribution

The results support involvement of family in the care of patients with SMI.

Affective Impact on Informal Caregivers over 70 Years of Age: A Qualitative Study

Given today's rapidly ageing society, family members providing informal care to dependent older adults face ever-increasing challenges. The aim of this study was to describe the affective impact on older adults over 70 years of age caring for a dependent older person at home. A qualitative study was designed from a phenomenological perspective. Thirteen in-depth interviews were conducted with caregivers aged 70 or older. A content analysis of the interviews was carried out in five stages. Three themes were identified: "Emotions", "Feelings", and "Looking to the future". Caregivers express negative emotions (sadness, anger, and fear) and feelings of social and emotional isolation, and they feel abandoned by health professionals, family, and friends. In conclusion, prolonged caregiving by older adults has a negative affective impact and creates uncertainty about the future. There is a need to devise social and healthcare policies and actions, creating social support networks to improve their health and emotional wellbeing.

"A Lonely Road to Walk Along" - The Experiences of Being a Next of Kin to a Woman in Need of Compulsory Psychiatric Inpatient Care

It is seldom that it is only the patient who is affected when someone is admitted to compulsory psychiatric inpatient care, the next of kin is usually also impacted. The aim was to describe the lived experiences of being a next of kin to a woman in need of compulsory psychiatric inpatient care. Ten next of kin were interviewed and the material was analyzed with a Reflective Lifeworld Research approach. The results show loneliness and feelings that their existence has collapsed. An emotional duality is described in the realization that the care is needed but they are devastated that the woman is there. A trust exists, but it changes when the next of kin are no longer a part of the care process.

Exploring the efficacy of a low intensity psychological intervention for family members and carers of individuals with a first episode of psychosis in early intervention services

AIM

The study aimed to evaluate the efficacy, and explore carers' experience, of a brief carer focussed intervention in an Early Intervention in Psychosis (EIP) service using a mixed methods approach.

METHODS

Carers within EIP services were invited to have the intervention, comprising a psychoeducation and wellbeing component, and 153 carers completed routine outcome measures including the Brief Experience of Caregiving Inventory (BECI), The Warwick-Edinburgh Mental Well-being Scale (WEMWEBS) and the Hospital Anxiety and Depression Scale (HADS) at baseline and after the completion of the intervention. Separately, nine carers took part in semi-structured interviews about their experience of the intervention.

RESULTS

The intervention resulted in improvement of overall well-being, a reduction in self-reported anxiety and caregiving experience relating to difficult behaviours and stigma/effects on the family. Overall, the carers' subjective experiences of the intervention were positive. Thematic analysis indicated epistemic trust indexed by the connection carers achieved with the service, an experience of being valued and of experiencing change through the intervention.

CONCLUSION

A short, 8 weeks intervention delivered by assistant psychologists, may offer an effective method for facilitating understanding of the illness and acclimatizing to new challenges. Exploring the effectiveness of psychoeducation and capturing this with specific measures may allow the service to make meaningful adaptations to their intervention.

Supporting patients by family education in psychotic illness: a longitudinal pre-post study protocol

INTRODUCTION

A lack of education, resources and support for family carers of young adults with psychotic illnesses leaves them ill-equipped to support their loved one. By equipping families with skills and knowledge, public healthcare harnesses a powerful ally to support community stabilisation.

AIMS

The primary goal is to study the effect of a psychoeducation intervention for family carers supporting young adults with psychosis on family burden and stabilisation of service users.

METHODS AND ANALYSIS

A longitudinal quantitative study with a pre-post design will be used to assess the long-term effectiveness of the psychoeducation intervention for family carers supporting a young adult with psychosis. 111 family carers will be recruited for the intervention and measures will be taken from family carer participants and their matched young adult service users. Nine evidence and family peer-informed and expert-reviewed psychoeducation modules are administered in 2-hour sessions over 9 weeks to family carers. Functional index measures are administered preintervention, and at 6-month, 12-month and 24-month follow-up. Service utilisation will be measured during a 12-month period preintervention, a 12-month period postintervention and during a 12-24-month period post-intervention.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the University of Alberta Research Ethics Board (Pro00110691). This novel methodological approach to studying family psychoeducation interventions addresses unique methodological challenges and limitations and will be disseminated through peer-reviewed publications and academic and medical conferences.

TRIAL REGISTRATION NUMBER

NCT05500001; National Institutes of Health U.S. National Library of Medicine ClinicalTrials.gov.

The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis

For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.

Moderated Online Social Therapy for Carers of Early Psychosis Clients in Real-World Settings: Cluster Randomized Controlled Trial

BACKGROUND

Family carers of youth recovering from early psychosis experience significant stress; however, access to effective family interventions is poor. Digital interventions provide a promising solution.

OBJECTIVE

Our objective was to evaluate across multiple Australian early psychosis services the effectiveness of a novel, web-based early psychosis intervention for carers.

METHODS

In this cluster randomized controlled trial conducted across multiple Australian early psychosis services, our digital moderated online social therapy for carers (Altitudes) plus enhanced family treatment as usual (TAU) was compared with TAU alone on the primary outcome of perceived stress and secondary outcomes including mental health symptoms and family variables at the 6-month follow-up.

RESULTS

Eighty-six caregivers were randomized and data were available for 74 young people in their care. Our primary hypothesis that carers randomized to Altitudes+TAU would report greater improvements in perceived stress at follow-up compared with carers randomized to TAU alone was not supported, with the TAU alone group showing more improvement. For secondary outcomes, the TAU alone group showed improved mindfulness over time. Regardless of group assignment, we observed improvements in satisfaction with life, quality of life, emotional overinvolvement, and burden of care. In contrast, hair cortisol concentration increased. Post hoc analyses revealed more contact with early psychosis services in the intervention group compared to TAU alone and that improvements in perceived stress and social support were associated with use of the intervention in the Altitudes+TAU group. In this study, 80% (12/15) reported a positive experience with Altitudes and 93% (14/15) would recommend it to others.

CONCLUSIONS

Our trial did not show a treatment effect for Altitudes in perceived stress. However, our post hoc analysis indicated that the amount of use of Altitudes related to improvements in stress and social support. Additional design work is indicated to continue users' engagement and to significantly improve outcomes in problem-solving, communication, and self-care.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12617000942358; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12617000942358.

Experiencing (Shared) Decision Making: Results from a Qualitative Study of People with Mental Illness and Their Family Members

(1) Background: There is a fundamental shift in healthcare toward shared decision making (SDM). This study explores SDM from the perspective of individuals affected by mental illness and their family members and investigates factors which promote and hinder the process. (2) Methods: We conducted N = 15 telephone interviews (n = 4 adults affected by mental illness, n = 5 family members, n = 6 both applicable, the majority reporting experiences with affective and anxiety disorders). Data were recorded, transcribed, and analyzed according to procedures established by Mayring. (3) Results: Individuals affected by mental illness and their family members have a strong desire to be involved in treatment decisions and to participate in finding a diagnosis. Often these stakeholders are denied the opportunity to participate; sometimes enabling behaviors impede participation. The stigmatization of mental illnesses is a major barrier. There are also structural barriers to SDM within the healthcare system. Peer support, self-help associations, and psychosocial counseling services are important to empowering individuals and promoting SDM. (4) Conclusions: SDM has the potential to improve the quality of mental healthcare. Barriers can be mitigated and new approaches for interventions in the psychiatric sector have been identified. This study has also shown the importance of understanding SDM as a process that should begin at the diagnostic phase.

Attitudes towards family involvement in nursing care among psychiatric nurses in Hong Kong: A cross-sectional descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Family-involved interventions can result in better outcomes than traditional mental health care for both service users and their families. Nurses' attitudes towards family involvement can affect family participation in care. Earlier studies on psychiatric nurses' attitudes towards family involvement in care report ambiguous findings. Hong Kong's unique integrated cultures may influence Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The majority of psychiatric nurses had positive views on family involvement in care in Hong Kong. Four variables (i.e. gender, clinical experience, nature of working unit and family nursing training) of psychiatric nurses are associated with their attitudes towards family involvement in care in Hong Kong. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Policy makers should develop strategies to increase psychiatric nurses' awareness of the importance of family involvement in patient care. Nurse educators help to design family nursing training to enhance psychiatric nurses' competence in collaborating with families of people suffering from mental disorders.

ABSTRACT

INTRODUCTION: In Hong Kong, involving the family in nursing care is still optional and mainly depends on nurses' attitudes and the willingness of the family. Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care may be influenced by the unique integrated Eastern and Western cultures, however earlier studies report ambiguous findings.

AIMS

This study aimed to assess Hong Kong psychiatric registered nurses' attitudes towards family involvement in care and its associated factors.

METHODS

This study is a cross-sectional descriptive online survey with convenience sampling based on the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) instrument.

RESULTS

Most of the psychiatric nurses had supportive attitudes towards family involvement in care. Females with more clinical experience, working in a rehabilitation-related unit and having attended a family nursing education course were associated with positive attitudes towards family involvement in care.

DISCUSSION

The supportive attitude of psychiatric nurses may be explained by the shift of mental health nursing care from hospital care to community care in recent decades.

IMPLICATIONS FOR PRACTICE

Mental health nurse education and training in Hong Kong could place more emphasis on building family work skills, particularly for newly qualified nurses and those working in acute inpatient settings.

Clinicians' perceptions of family involvement in the treatment of persons with psychotic disorders: a nested qualitative study

Background

Family involvement in mental health care ranges from basic practices to complex interventions such as Family psychoeducation, the latter being a well-documented treatment for psychotic disorders. The aim of this study was to explore clinicians' perceptions of the benefits and disadvantages of family involvement, including possible mediating factors and processes.

Methods

Nested in a randomised trial, which purpose was to implement Basic family involvement and support and Family psychoeducation in Norwegian community mental health centres during 2019-2020, this qualitative study is based on eight focus groups with implementation teams and five focus groups with ordinary clinicians. Using a purposive sampling strategy and semi-structured interview guides, focus groups were audio-recorded, transcribed verbatim, and analysed with reflexive thematic analysis.

Results

Four main themes were identified as perceived benefits: (1) Family psychoeducation-a concrete framework, (2) Reducing conflict and stress, (3) A triadic understanding, and (4) Being on the same team. Themes 2-4 formed an interconnected triad of mutually reinforcing elements and were further linked to three important clinician-facilitated sub-themes: a space for relatives' experiences, emotions and needs; a space for patients and relatives to discuss sensitive topics and an open line of communication between clinician and relative. Although far less frequent, three main themes were identified as perceived disadvantages or challenges: (1) Family psychoeducation-occasional poor model fit or difficulties following the framework, (2) Getting more involved than usual, and (3) Relatives as a potentially negative influence-important nonetheless.

Conclusions

The findings contribute to the understanding of the beneficial processes and outcomes of family involvement, as well as the critical role of the clinician in achieving these and possible challenges. They could also be used to inform future quantitative research on mediating factors and implementation efforts.

"The most important thing is that those closest to you, understand you": a nested qualitative study of persons with psychotic disorders' experiences with family involvement

Introduction

Family interventions constitute effective treatment for persons with psychotic disorders. However, the active ingredients and beneficial processes of these interventions are insufficiently examined, and qualitative explorations of patients` experiences are lacking. This study was nested in a cluster randomised trial that implemented national guidelines on family involvement in Norwegian community mental health centres, including family psychoeducation and basic family involvement and support. The aim of this sub-study was to explore how patients with psychotic disorders experience systematic family involvement, and its significance.

Methods

We conducted semi-structured, individual interviews with 13 persons with a psychotic disorder after systematic family involvement. The participants were recruited through purposive sampling. Qualitative content analysis guided the analysis.

Results

Participants reported overall positive experiences with systematic family involvement. It was significant that the relatives increasingly understood more about psychosis and their situation, while they themselves also gained more insight into the relatives` situation. The participants emphasised the need to enable both patients and relatives to safely share experiences in a containing space, led by professionals. Shared understanding and awareness of each other's situation further improved communication, coping with the illness, reduced stress, and stimulated a more caring family environment. The therapist seemed crucial to facilitate these beneficial communication processes, and also to provide continuous support to the relatives. Reported challenges included that the participants felt vulnerable in the initial phase, a need for tailored approaches, and too late start-up.

Conclusion

Findings from this study suggest that persons with psychotic disorders may benefit greatly from participating in systematic family involvement. This study also gives new insight into possible mediators of positive outcomes both for the patients and the relatives. Systematic family involvement should be implemented a standard approach in the early phase of the disease, using a step-wise and tailored process.

The contribution of anthropology to the study of Open Dialogue: ethnographic research methods and opportunities

When Open Dialogue diversifies internationally as an approach to mental healthcare, so too do the research methodologies used to describe, explain and evaluate this alternative to existing psychiatric services. This article considers the contribution of anthropology and its core method of ethnography among these approaches. It reviews the methodological opportunities in mental health research opened up by anthropology, and specifically the detailed knowledge about clinical processes and institutional contexts. Such knowledge is important in order to generalize innovations in practice by identifying contextual factors necessary to implementation that are unknowable in advance. The article explains the ethnographic mode of investigation, exploring this in more detail with an account of the method of one anthropological study under way in the UK focused on Peer-Supported Open Dialogue (POD) in the National Health Service (NHS). It sets out the objectives, design and scope of this research study, the varied roles of researchers, the sites of field research and the specific interaction between ethnography and Open Dialogue. This study is original in its design, context, conduct and the kind of data produced, and presents both opportunities and challenges. These are explained in order to raise issues of method that are of wider relevance to Open Dialogue research and anthropology.

Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP): A Cluster Randomised Controlled Trial

Family involvement is part of the evidence-based treatment for persons with psychotic disorders, yet is under-implemented despite guideline recommendations. This study assessed whether an implementation support programme increased the adherence to guidelines on family involvement, compared to guideline/manual only. In a cluster randomised design, community mental health centre units in South-East Norway went through stratified allocation to the experimental (n = 7) or control (n = 7) arm. Experimental clusters received an implementation support programme including clinical training and supervision, appointing a family coordinator and an implementation team, a toolkit, and fidelity measurements at baseline, 12, 18, and 24 months with on-site feedback and supervision. Control clusters received no such support and had fidelity measurements at baseline and 24 months without feedback. During fidelity measurements, adherence to the guidelines was measured with the basic family involvement and support scale, the general organizational index, and the family psychoeducation fidelity scale, the latter being the primary outcome. The scales consist of 12-14 items rated from 1 to 5. Data was analysed with an independent samples t-test, linear mixed models, and a tobit regression model. At 24 months, the mean scores were 4.00 or higher on all scales in the experimental arm, and the increase in adherence to the guidelines was significantly greater than in the control arm with p-values < 0.001. Large-scale implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres may be accomplished, with substantial implementation support.Trial Registration: ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

A Balancing Act: A Systematic Review and Metasynthesis of Family-Focused Practice in Adult Mental Health Services

Parental mental illness is a major international public health concern given its implications for whole families, including children. Family-focused practice (FFP), an approach that emphasises a "whole-family" approach to care, provides an opportunity to mitigate the significant risks associated with parental mental health difficulties. The positive benefits associated with FFP have led to a shift in policy and practice towards prioritising FFP within adult mental health services. However, evidence suggests that FFP remains scarce and is not routine. Research has identified the important role of practitioners in facilitating FFP. The current review identified, synthesised and appraised the international qualitative literature examining adult mental health practitioners' implementation experiences of FFP. It aimed to provide an evidence-informed account of practitioner experiences of FFP delivery and to identify key recommendations to enhance future FFP outcomes in AMHS. Ovid Medline, PsycInfo, CINAHL plus, EMBASE and Web of Science Core Collection were searched systematically, in line with PRISMA guidance, up to January 2022. The Critical Appraisal Skills Programme (CASP) was used to undertake the quality appraisal prior to a thematic synthesis being conducted. The review was registered on PROSPERO. Nineteen papers, spanning 17 years of research with 469 practitioners, were included. Three main themes and 14 subthemes were developed, representing different aspects of practitioner experiences of FFP delivery. Practitioners' approach to FFP was variable and influenced by their beliefs about FFP, perceived roles and responsibilities, competence, service setting, and personal parenting status. Practitioners engaged in a balancing act to maintain a dual focus on their service-users and their children, to navigate powerful emotions, and consider multiple perspectives in a biomedical organisational structure that advocates individualised treatment. Although working together unified teams, a greater need for external interagency collaboration was identified. The use of strength-based approaches with clients and dedicated staff resources, within clear guidelines and frameworks, was reported to be necessary to maximise FFP delivery. This review proposes a complex FFP dynamic whereby practitioners engage in a constant balancing act between FFP stakeholders to achieve meaningful FFP outcomes for service-users and their families. Service recommendations are provided.

Exploring service user perspectives of behavioural family therapy in early intervention in psychosis

AIMS

Family intervention (FI) is recommended in national guidance to be offered to all service users accessing an early intervention in psychosis (EIP) team, due to the consistent evidence base in reducing relapse and rehospitalisation rates. However, FI implementation is poor nationally. Although barriers have been identified at the level of staff member and the organisation, there is a paucity of research identifying service user perspectives.

METHODS

A qualitative questionnaire design was used to explore service user perspectives of behavioural family therapy (BFT) within a specialist EIP service in northwest England.

RESULTS

Most participants contacted reported they lacked knowledge and understanding of BFT, with 54% reporting that this intervention had not been offered to them. This finding was unexpected and is inconsistent with the offer of BFT documentation in their clinical notes. Reasons for accepting BFT included to increase understanding of family members and for them to also be supported. Reasons for declining BFT included a preference for one-to-one interventions and not wanting family involved in their care.

CONCLUSIONS

National guidance on FI for psychosis is not reliably being translated to clinical practice, with many participants reporting that they were not offered this intervention. A key factor in accepting or declining an offer of BFT appeared to be whether participants wanted family members to be involved in their care. A lack of understanding of the BFT approach was evident, it is recommended that the offer of FI in psychosis is improved for service users to make an informed decision.

Operationalising a Recovery-Oriented Support and Information Programme Online: The EOLAS Programme

Evidence demonstrates that psychoeducation interventions have clinical and recovery-related benefits for people experiencing psychosis and their family members. The EOLAS programmes are one example of recovery-oriented psychoeducation programmes for psychosis. They differ from other programmes in that they are co-designed and co-facilitated (peer and clinician) group programmes. Due to the COVID-19 pandemic, EOLAS went online using a videoconferencing platform. The study examined the feasibility, acceptability and usefulness of EOLAS-Online and explored whether some of the positive recovery outcomes reported by attendees regarding the in-person programmes were replicated online. Data were collected through an online survey and semi-structured interviews. Quantitative data were analysed using descriptive statistics. Thematic analysis was used for qualitative data. Fifteen attendees (40% of attendees) completed the surveys and eight participated in interviews. A total of 80% were satisfied/very satisfied with the programme. The programme was rated highly for increased knowledge of mental health, coping strategies, and engaging with peers. The use of technology was mostly unproblematic, although some audio and video-related challenges were identified. Engaging with the online programme was experienced positively, including facilitator support to engage. The overall findings indicate that EOLAS-Online is feasible, acceptable and useful in supporting attendees' recovery journeys.

Caregivers' experiences and perspectives of factors associated with relapse in Iranian people living with schizophrenia: A qualitative study

BACKGROUND

Relapse in People Living with Schizophrenia (PLS) has several reasons and recognizing these can increase the effectiveness of treatment interventions. Formal and informal caregivers are an informed source to reduce relapse in PLS.

AIM

This study explores the caregivers' perspective in Iran on the factors affecting relapse in PLS.

METHOD

A total of 28 caregivers (16 formal caregivers and 12 informal caregivers) of PLS were enrolled in our qualitative study. A content analysis was conducted using individual and group, semi-structured in-depth interviews with informal and formal caregivers of PLS. This study was conducted in a hospital, three universities, and a non-governmental organization in Tehran, Iran.

RESULTS

The majority (69%) of the participants were females. About half of the informal caregivers were over 60 years old and about 40% of the formal caregivers were in the age range of 30 to 40 years. The average number of years of work for informal caregivers was 17.6 years and the average of work experience among the formal caregivers was 14.1 years. Seven key dual themes were identified from data: 'awareness-stigma', 'social support-social exclusion', 'treatment adherence-treatment discontinuation', 'holistic approach - one-dimensional approach', 'supported employment-social dysfunction', 'emotional management in family - family with high emotional expression', and 'access to treatment-treatment gap'.

CONCLUSION

The results of this research can help practitioners and policymakers to enable evidence-based practices to reduce relapse in PLS by emphasizing and acting on factors identified in our analyses.

Experience, impact and needs of informal parental caregivers around the communication of a diagnosis of schizophrenia

AIMS

To qualitatively characterize the experience, impact and needs of informal family caregivers around the communication of a diagnosis of schizophrenia.

METHODS

In all, 13 informal family caregivers were recruited. All were parents. Semi-structured interviews were used to explore their experience of the diagnosis of schizophrenia, the impacts of the diagnosis and the needs related to the diagnosis around its communication. Interviews were recorded, transcribed, codes generated and mixed deductive-inductive thematic analysis undertaken.

RESULTS

Participants described receiving the diagnosis of schizophrenia for their relative as a devastating experience, although some nuanced the experience with a sense of relief of finally naming the disorder and getting access to care. Caregivers' experience and representations prior to hearing the diagnosis played an important role in the way the 'news' was internalized. The communication of the diagnosis constituted a starting point for acceptance of the reality of the illness in participants. Numerous unmet needs around the communication of the diagnosis were reported by participants, including personnalized support, specific explanations about the disorder and guidance on their role as caregiver.

CONCLUSION

A specific attention must be given to the communication of the diagnosis of schizophrenia to the informal family caregivers. Information giving must be early, comprehensive, personalized and embedded into tailored education and support programmes for caregivers to facilitate illness acceptance and adaptation.

The duty of confidentiality during family involvement: ethical challenges and possible solutions in the treatment of persons with psychotic disorders

BACKGROUND

Family involvement during severe mental illness is still poorly implemented, contrary to evidence-based recommendations. Confidentiality issues are among the most prominent barriers, with mental health professionals facing complex ethical, legal, and practical challenges. However, research focusing on this barrier is very sparse. Nested within a cluster-randomised trial to implement guidelines on family involvement for persons with psychotic disorders in community mental health centres, the aim of this sub-study was to explore ethical challenges related to the duty of confidentiality as experienced by mental health professionals, and to explore key measures that might contribute to improving the handling of such challenges.

METHODS

In total 75 participants participated in 21 semi-structured focus groups, including implementation team members at the initial and late phase of the intervention period and clinicians who were not on the implementation teams, at late phase of implementation. We used purposive sampling and manifest content analysis to explore participants' experiences and change processes.

RESULTS

Ethical challenges related to the duty of confidentiality included 1) Uncertainty in how to apply the legislation, 2) Patient autonomy versus a less strict interpretation of the duty of confidentiality, 3) Patient alliance and beneficence versus a less strict interpretation of the duty of confidentiality, 4) How to deal with uncertainty regarding what relatives know about the patients' illness, and 5) Relatives' interests versus the duty of confidentiality. Measures to facilitate better handling of the duty of confidentiality included 1) Training and practice in family involvement, and 2) Standardisation of family involvement practices.

CONCLUSION

When health professionals gained competence in and positive experiences with family involvement, this led to vital changes in how they interpreted and practiced the duty of confidentiality in their ethical reasoning and in clinical practice. Especially, the need to provide sufficient information to the patients about family involvement became evident during the study. To improve the handling of confidentiality issues, professionals should receive training in family involvement and confidentiality statutes followed by practice. Furthermore, family involvement should be standardised, and confidentiality guidelines should be implemented in the mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Involving families in Veteran mental health care: Key considerations and recommendations

LAY SUMMARY

When Veterans seek and receive mental health care, their family members are often involved, directly or indirectly, in the process. Within Canada, recognition of the need for family-centred policies and practices is growing; however, family involvement in care is generally the exception rather than the rule. A recently developed Conceptual Framework advocates for a transformed mental health system centred on the experiences, needs, and preferences of Veterans and their families. This system may be well suited to a shift toward family-involved care. Drawing on this framework, this article makes a case for specifically involving families in Veteran mental health care. In particular, the crucial relationship between family and Veteran well-being is considered, as well as key benefits of and potential barriers to involvement. With these considerations in mind, some recommendations are made to move research, practice, and policy forward. These include 1) formalizing the definition of family, 2) developing a more comprehensive and nuanced understanding of Veteran families and their involvement, and 3) using educational and guidance materials to improve knowledge and build capacity. Despite potential limitations, these considerations and recommendations offer an opportunity to advance dialogue related to meaningful and safe involvement of families in Veteran mental health care.

"It's still our child". A qualitative interview study with parent carers in forensic mental health

The purpose of this study was to explore the experiences and perceptions of parents in forensic mental health services with regard to their cooperation with healthcare professionals and their role as parent carers. 15 participants were interviewed using qualitative, in-depth interviews and transcripts were analysed thematically. The identified themes were 'Medical dominance', 'Interactions with healthcare professionals', and 'Advocating for their daughter/son'. The themes were associated with the overall theme 'perceived impact on the parents' everyday lives'. The results suggest that parent carers perceive a malalignment between the institutional medicalised treatment focus and the need for an integrated holistic approach, which would include them as partners.

Effects of the family support and psychoeducation program based on the Calgary Family Intervention Model on the coping, psychological distress and psychological resilience levels of the family caregivers of chronic psychiatric patients

AIMS

This study was aimed at investigating the effects of family support and psychoeducation program based on Calgary Family Intervention Model on coping, psychological distress and psychological resilience levels of families of chronic psychiatric patients.

METHODS

The sample of this quasi-experimental study consisted of the caregivers of chronic psychiatric patients who were admitted to the adult psychiatry inpatient and outpatient unit of a university hospital and the caregivers of chronic psychiatric patients registered with the Schizophrenia Solidarity Association. Nonparametric analysis was used in the analysis of the data.

RESULTS

It was found that there was a significant decrease between the mean distress scores the caregivers participating in the Calgary Family Intervention-Based Family Support and Psychoeducation Program obtained from the measurements before, right after, and 3 and 6 months after the intervention (p < 0.05). There was no statistically significant difference between the coping scores and psychological resilience scores the caregivers obtained from the measurements before, right after, and 3 and 6 months after the intervention (p > 0.05).

CONCLUSION

It was concluded that the family support and psychoeducation program based on the Calgary Family Intervention Model applied to family members giving care to individuals with chronic mental illnesses had positive effects on the general health status of the caregivers.

Scoping review of factors influencing the implementation of group psychoeducational initiatives for people experiencing mental health difficulties and their families

BACKGROUND

Despite evidence to support the effectiveness of psychoeducation for people experiencing mental health difficulties and their families, understanding issues around the implementation of such programmes is limited.

AIM

The aim of this scoping review was to synthesise the peer-reviewed literature on barriers and enablers influencing the implementation of group psychoeducation in adult mental health services.

METHODS

Using a pre-defined search strategy and PRISMA guidelines, four databases were systematically searched. Two reviewers independently screened and applied exclusion/inclusion criteria. Qualitative, quantitative, and mixed-methods studies were included if they provided empirical evidence on the barriers and enablers. Three reviewers independently extracted data. Following this, data were analysed using a five-level implementation framework.

RESULTS

Eight articles met the inclusion criteria. Barriers to implementation were identified at all five levels of the framework: participant; practitioner; intervention; organisational; and structural level. Enablers to implementation were evident at four levels: participant; provider; intervention; and organisational level.

CONCLUSIONS

The findings of the review provide preliminary information on factors that impact implementation. However, large-scale studies informed by implementation theories are required. In addition, other studies are needed to address the potential impact of different models of intervention and explore strategies to minimize obstacles and support sustainability.

Middle-aged and older people with urgent, unaware, and unmet mental health care needs: Practitioners' viewpoints from outside the formal mental health care system

BACKGROUND

Mental health challenges are highly significant among older individuals. However, the non-utilization of mental health services increases with age. Although universal health coverage (UHC) was reported to reduce unmet health care needs, it might not be sufficient to reduce unmet mental health care needs from a clinical perspective. Despite the existence of UHC in Japan, this study aimed to explore the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs.

METHODS

Purposeful sampling was used as the sampling method in this study by combining snowball sampling and a specific criterion. The interviewees were nine practitioners from four sectors outside the mental health care system, including long-term care, the public and private sector, as well as general hospitals in one area of Tokyo, where we had conducted community-based participatory research for five years. The interviews were conducted by an interdisciplinary team, which comprised a psychiatrist, a public health nurse from a non-profit organization, and a Buddhist priest as well as a social researcher to cover the broader unmet health care needs, such as physical, psychosocial, and spiritual needs. The basic characteristics of the interviewees were enquired, followed by whether the interviewees had case of middle-aged or older individuals with urgent, unaware, and unmet mental health care needs. If the answer was yes, we asked the interviewees to describe the details. The interviews pertinent to this study were conducted between October 2021 and November 2021. In this study, we adopted a qualitative descriptive approach. First, we created a summary of each case. Next, we explored the factors related to the non-utilization of formal mental health care systems by conducting a thematic analysis to identify the themes in the data collected.

RESULTS

The over-arching category involving "the factors related to an individual person" included two categories, as follows: 1) "Individual intrinsic factors," which comprised two sub-categories, including "difficulty in seeking help" and "delusional disorders," and 2) "family factors," which comprised "discord between family members," "denial of service engagement," "multiple cases in one family," and "families' difficulty in seeking help." The over-arching category "the factors related to the systems" included four categories, as follows: 1) "Physical health system-related factors," which comprised "the indifference of physical healthcare providers regarding mental health" and "the discontinuation of physical health conditions," 2) "mental health system-related factors," which comprised "irresponsive mental health care systems" and "uncomfortable experiences in previous visits to clinics," and 3) "social service system-related factors," which comprised "the lack of time to provide care," "social service not allowed without diagnosis," and "no appropriate service in the community," as well as 4) " the lack of integration between the systems." Apart from the aforementioned factors, "the community people-related factor" and "factors related to inter-regional movements" also emerged in this study.

CONCLUSIONS

The results of this study suggest a specific intervention target, and they provide further directions for research and policy implementation. The suggested solutions to the issues pertinent to this study are as follows: the recognition of the ways in which older people may inadequately understand their health or be unaware of available services, the building of a therapeutic alliance for "the individual intrinsic factors." Regarding the "family factors," the solutions include the provision of particularly intensive care for families with family discords, families with multiple cases, and families who find it difficult to seek help, as well as making intensive efforts for ensuring early involvement after contact with health care services. Regarding the "the factors related to the systems," the solutions include the implementation of mental health education campaigns aimed at enhancing mental health knowledge among non-mental health professionals, as well as formulating and implementing reforms ensuring that such professionals are increasingly responsible especially with regard to emergency inpatient care. It also include listening without ageism in clinical practice, the expansion of social services regarding human resources and the flexibility of use which increases the breadth of the types of care, as well as facilitating the integration between the associated health care systems. Further suggestions include encouraging community residents to join social security systems as well as the provision of particularly intensive care for people who have just moved in.

Family Intervention in Severe Mental Disorder: An Online Intervention Format in Psychosocial Rehabilitation Centers

The use of new technologies and online interventions with family members of people affected by severe mental disorders (SMD) seems to emerge as a promising complementary strategy to face-to-face care. The article presents a new online intervention format, aimed at relatives of people with SMD. A qualitative methodology sequenced in seven phases has been used. (1) The incorporation of relatives into the programme has allowed the intervention format to be adapted to the needs and opinions of the relatives themselves. (2) All the relatives were completely satisfied with the new online intervention format, and with how useful it had been for them. (1) The attention and support to family members of people with SMD through the Internet is a complementary intervention strategy to face-to-face care. (2) The online format of attention to family members can be incorporated into the usual practice of care services.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40737-022-00310-7.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study

Background

The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.

Methods

We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.

Results

Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.

Conclusions

Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.

Trial registration

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08489-y.

Service User and Carer Views and Expectations of Mental Health Nurses: A Systematic Review

Service users' views and expectations of mental health nurses in a UK context were previously reviewed in 2008. The aim of this systematic review is to extend previous research by reviewing international research and work published after the original review. Five databases were searched for studies of any design, published since 2008, that addressed service user and carer views and expectations of mental health nurses. Two reviewers independently completed title and abstract, full-text screening and data extraction. A narrative synthesis was undertaken. We included 49 studies. Most included studies (n = 39, 80%) were qualitative. The importance of the therapeutic relationship and service users being supported in their personal recovery by mental health nurses were core themes identified across included studies. Service users frequently expressed concern about the quality of the therapeutic relationship and indicated that nurses lacked time to spend with them. Carers reported that their concerns were not taken seriously and were often excluded from the care of their relatives. Our critical appraisal identified important sources of bias in included studies. The findings of our review are broadly consistent with previous reviews however the importance of adopting a recovery approach has emerged as a new focus.

A comparison of experiences of care and expressed emotion among caregivers of young people with first-episode psychosis or borderline personality disorder features

OBJECTIVE

Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with 'first-presentation' borderline personality disorder features.

METHOD

Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN12616000304437, ACTRN12618000616279). Caregivers completed self-report measures of experiences of the caregiver role and expressed emotion. Multivariate generalised linear models and moderation analyses were used to determine group differences.

RESULTS

Data were available for 265 caregivers. Higher levels of negative experiences and expressed emotion, and stronger correlations between negative experiences and expressed emotion domains, were found in caregivers of young people with borderline personality disorder than first-episode psychosis. Caregiver group (borderline personality disorder, first-episode psychosis) moderated the relationship between expressed emotion and caregiver experiences in the domains of need to provide backup and positive personal experiences.

CONCLUSION

Caregivers of young people with borderline personality disorder experience higher levels of negative experiences related to their role and expressed emotion compared with caregivers of young people with first-episode psychosis. The mechanisms underpinning associations between caregiver experiences and expressed emotion differ between these two caregiver groups, indicating that different supports are needed. For borderline personality disorder caregivers, emotional over-involvement is associated with both negative and positive experiences, so a more detailed understanding of the nature of emotional over-involvement for each relationship is required to guide action.

Mental health service users' experiences and perspectives of family involvement in their care: a systematic literature review

Background: The importance of engaging families in mental health care is recognised and endorsed by governments worldwide, however service users' perspectives of family involvement are not well understood.Aims: This study sought to summarise the literature regarding how service users view the involvement of family in their engagement with services and care.Methods: A search was conducted within the following databases for manuscripts published in the last 10 years: PsycINFO, CINAHLPlus, PubMed and Scopus. Of the 4251 eligible papers 17 met the inclusion criteria for review and were subjected to quality appraisal using the RATS (relevance, appropriateness, transparency, soundness) qualitative research review guidelines.Results: Thematic analysis identified four primary themes: family involvement can be positive and negative; barriers to family involvement; family involvement is variable; and communication and collaboration among stakeholders.Conclusions: Identifying the barriers to family involvement and heterogeneity among service users' views were key findings of this review. Despite the widely reported benefits of including families in mental health care it does not always occur. A clearer and more nuanced understanding of service users' needs and preferences for family involvement is required.

COVID-19 lockdown - who cares? The first lockdown from the perspective of relatives of people with severe mental illness

Background

Informal care is vital to many people with severe mental illness under normal circumstances. Little is known about how extraordinary circumstances affect relatives with a family member with mental illness. This study investigated the consequences of the first COVID-19 lockdown in Norway from the perspective of relatives of persons with psychotic- and/or bipolar disorders: What were the challenges and for whom?

Method

Relatives were invited to complete an online survey shortly after the first lockdown was initiated. Both quantitative and qualitative data were collected concerning experiences of relatives’ own and their affected family members’ health and situation. Two hundred and seventy-nine relatives completed the survey, mostly mothers and partners.

Results

One-third of the relatives reported considerable deterioration in their family members’ mental health, and a substantial minority worried about severe self-harm or suicide. Main themes in the qualitative analyses were “Isolation and its effects on mental health”, “Worrying about the pandemic and its consequences”, “Increased symptomatology” and “Suicide”. Being a relative during the lockdown put heavy strain on the relatives’ own health, in particular disturbance of sleep, concentration, and the ability to take care of others in the family. Relatives of family members with psychotic bipolar disorder, not currently in treatment, or living with their family experienced the situation especially challenging.

Conclusions

Many relatives found the first lockdown hard for their family. Efforts to integrate relatives’ perspectives in health care and contingency plans under normal circumstances could potentially alleviate some of the extra burden experienced by families during extraordinary circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13458-5.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Experience of Caregivers with First-Episode Psychosis Children at General Hospital of Dumai, Riau Province

BACKGROUND: Caregivers with first-episode psychosis (FEP) children often encounter problems and challenges. The importance of caregiver role in managing FEP appropriately will influence the life quality of a person with psychosis. AIM: The study aimed to explore the experience of caregivers who have children with FEP at General Hospital of Dumai. METHODS: The study was a qualitative study with a phenomenology approach. In-depth interviews were conducted with eight primary caregivers aged 41–58 years with FEP children at General Hospital of Dumai. The interview transcript was analyzed using the Colaizzi method. RESULTS: Based on the study, five essential themes emerged, for example, caring for FEP is harder than looking after a thousand buffaloes, mixed feelings, believing that the child experiences mystical things, the extended family is a supporter in caring for FEP, and praying and surrender to God. CONCLUSION: The implications for nursing practice are implementing support group therapy and family psychoeducation programs for reduce the caregiver burden.

Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement

Background

Posttraumatic stress disorder occurs in as many as one in five combat veterans and is associated with a host of negative, long-term consequences to the individual, their families, and society at large. Trauma-focused treatments, such as Prolonged Exposure, result in clinically significant symptom relief for many. Adherence to these treatments (i.e., session attendance and homework compliance) is vital to ensuring recovery but can be challenging for patients. Engaging families in veterans’ treatment could prove to be an effective strategy for promoting treatment adherence while also addressing long-standing calls for better family inclusion in treatment for posttraumatic stress disorder. This paper describes the methods of a pragmatic randomized controlled trial designed to evaluate if family inclusion in Prolonged Exposure can improve treatment adherence.

Methods

One hundred fifty-six veterans, with clinically significant symptoms of posttraumatic stress disorder, will be randomized to receive either standard Prolonged Exposure or Prolonged Exposure enhanced through family inclusion (Family-Supported Prolonged Exposure) across three different VA facilities. Our primary outcomes are session attendance and homework compliance. Secondary outcomes include posttraumatic stress disorder symptom severity, depression, quality of life, and relationship functioning. The study includes a concurrent process evaluation to identify potential implementation facilitators and barriers to family involvement in Prolonged Exposure within VA.

Discussion

While the importance of family involvement in posttraumatic stress disorder treatment is non-controversial, there is no evidence base supporting best practices on how to integrate families into PE or any other individually focused trauma-focused treatments for posttraumatic stress disorder. This study is an important step in addressing this gap, contributing to the literature for both retention and family involvement in trauma-focused treatments.

Trial registration

ClinicalTrials.govNCT03256227. Registered on August 21, 2017.

It Takes a Village to Raise a Child: Understanding and Expanding the Concept of the “Village”

This perspective article defines and discusses the concept of the “village” when working with families who are experiencing multiple adversities. The article starts with a discussion on what is meant generally by a village approach, followed by a historical overview of how families living in adversity have been defined and positioned. The need to move past a siloed, professional centric approach when working with families is then presented. Using a model of social connections, based on Bronfenbrenner's ecological theory, we then identify who the “villagers” might be. Some potential principles for how the village might work with families living with adversity are presented, along with two case studies, to demonstrate how these principles might be enacted. This perspective article provides an overview and discussion of “the village” concept, rather than present a definitive set of guidelines or recommendations.

Locked out during COVID-19 lockdown—an online survey of relatives of people with psychotic and bipolar disorders in Norway

Background

Many relatives of people with psychotic and bipolar disorders experience a high caregiver burden normally. During the first COVID-19 lockdown, mental health services partly shut down in many countries. The impact on relatives is unknown.

Aims

Explore how relatives of people with psychotic and bipolar disorders experienced changes in treatment and service availability for their family member during the first COVID-19 pandemic lockdown in the spring of 2020, and to what extent they perceived information and support to be satisfactory. To help guide future contingency plans, we were also interested in what relatives would prioritize in the event of a future crisis.

Study setting

We distributed an anonymous Norwegian online survey inviting relatives of individuals with psychotic and bipolar disorders. We distributed the survey using social media, through snowball sampling, collecting both quantitative and qualitative data. The survey was available between May and June 2020. We used systematic text condensation to analyse qualitative data.

Results

Two hundred and seventy-nine respondents replied, mostly mothers and partners. A majority experienced a reduction in health care for their family member. Most respondents did not receive any support during the lockdown. However, most found the information they received from the mental health services regarding their family members’ treatment as sufficient. The qualitative data analysis revealed that relatives experienced three major challenges: reductions in treatment for the family member; reduced organised daily activity for the family member; and an increased caretaker load. In the case of a future lockdown, they would prefer increased access to care compared with a normal situation; increased support for relatives; and enhanced information.

Conclusions

Mental health services in Norway did not manage to meet the needs of patients with severe mental illness and their relatives during the first COVID-19 lockdown. To be better prepared, Norwegian mental health services should consider prioritising infrastructure to ensure access to care and support for both patients and relatives. Digital tools and telephone calls are generally well accepted as substitutes for face-to-face contact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12625-y.

Storytelling and training to advance individual recovery skills (STAIRS). A feasibility study of a blended program to support personal recovery among patients with a major depressive disorder in remission

Because major depressive disorder (MDD) has a strong negative impact on patients' lives, well-designed treatment programs are needed that address the lasting effects of MDD. Previous work has shown that such programs should not only focus on symptomatic recovery, but also on the subsequent personal recovery process. Currently, few programs with this specific focus exist. Therefore, this study aimed to assess the feasibility of a newly developed blended program to support the personal recovery process of MDD patients: Storytelling and Training to Advance Individual Recovery Skills (STAIRS). STAIRS is a program using peer support and guidance by experts by experience and clinicians, which can be added to regular depression treatment when symptomatic recovery is almost reached. Topics addressed in this program are: (1) effects of depression and treatment; (2) structure; (3) (self) stigma; (4) self-image; (5) meaning of life; (6) connection to others; (7) physical health; (8) relaxation; and (9) preventing relapse. Experiences with the STAIRS program were collected from five participating patients with questionnaires and a focus-group interview, as well as from four trainers using semi-structured interviews. Participants valued the topics addressed in STAIRS, the used working methods, the presence of an expert by experience and the ability to share experiences with peers. The use of an online platform and the involvement of others is seen as potentially supportive but turned out to be more challenging. Perceived effects of STAIRS include positive changes in participants' daily lives and their contacts with others. Overall, the results indicate that when implemented accessibly, STAIRS is a promising and feasible program to foster personal recovery among patients recovering from MDD.

Implementation of first episode psychosis intervention in India - A case study in a low-and middle-income country

First Episode Psychosis (FEP) is a serious mental illness affecting adolescents and young persons. While many effective interventions are available, there has not been much research to understand the implementation of such interventions in India and other low- and middle-income countries (LMIC). We studied the implementation of an FEP intervention program in a specialist mental health facility in Chennai, India, using a well-established framework for doing so, the Consolidated Framework for Implementation Research (CFIR). We conducted 27 in-depth interviews with the service users (15 persons with FEP and 12 family caregivers of persons with FEP). We also conducted a focus group discussion with 8 service providers and in-depth interviews with 7 other service providers including those in the service management. A thematic analysis approach was used to identify emerging themes. First, we found CFIR effectively accommodated implementation challenges evident in LMICs; that is, it is transferable to LMIC settings. Second, we highlight barriers to implementation that include cost, limited human resources, cultural and professional hierarchy, divergence from evidence-based guidelines, and lack of awareness and stigma in the wider community. Third, we highlight facilitators for implementation such as, leadership engagement, the need for change that was recognized within the service, cosmopolitan perspectives derived from clinicians’ local and international collaborative experiences and expertise, compatibility of the intervention with the existing systems within the organization, accommodating the needs of the service users, and rapport developed by the service with the service users. Fourth, we propose a model of service delivery incorporating a task-sharing approach for first episode psychosis in resource restricted settings based on the feedback from the stakeholders.

•

Implementation of interventions for First Episode Psychosis in India is explored systematically.

•

Resource constraints, cultural factors, lack of awareness, and stigma are the main barriers to the implementation.

•

Buy-in from the service providers, accommodating the needs and developing rapport with the service users are the facilitators.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial

IMPORTANCE

Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice.

OBJECTIVE

To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI.

DESIGN, SETTING, AND PARTICIPANTS

This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed.

INTERVENTIONS

In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG.

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List.

RESULTS

A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months.

CONCLUSIONS AND RELEVANCE

These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL6548.

Late ‘Early Intervention in Psychosis’: A Family School for Learning How to Live with Schizophrenia

The paper describes a family school for learning how to live with schizophrenia, which was founded in 1986 in Vienna, Austria, and is still running today. It was established in cooperation between professionals and the Austrian self-help association HPE of the relatives of persons with mental disorders. It addresses the needs of 10 families at a time, in cases where a son or a daughter was diagnosed with schizophrenia and had already experienced one or several episodes of the illness. The course lasts one and a half years and is organized according to the model of a weekly boarding school, where 10 children, the residents, stay in the school overnight from Sunday evening to Friday and take part in a structured program on cognitive, social and practical life skills. Ambulatory psychiatric treatment is taking place concurrently outside the school through local routine services. On weekends residents stay with their parents since the school is closed. Parents visit the school regularly to take part in joint activities with the residents. They also undertake night shifts in the school and attend a weekly parents group. In the regular encounters during everyday activities in the school, learning by doing occurs parents get to know the daughters and sons of other families and can learn to distinguish between disease-related and personality-related behavior. Residents can have similar learning experiences in relation to the parents of other residents. The main aim of the school is that parents learn to provide protected autonomy for the daughters or sons in question, in order to assist them after the end of the course in leading a life characterized by as much autonomy as possible after the end of the school.