How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis

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.

Early intervention in psychosis for first episode psychotic mania: the experience of people diagnosed with bipolar disorder

BACKGROUND

Early intervention for people diagnosed with bipolar disorder has been identified as a priority, but little is known about how existing early intervention services are experienced by this group or could be tailored to their needs.

AIMS

This study examined the experience of early intervention in psychosis (EIP) services for people diagnosed with bipolar disorder, following first episode psychotic mania.

METHOD

Semi-structured interviews were conducted with 11 adults in EIP services and analysed using Interpretative Phenomenological Analysis.

RESULTS

One superordinate theme was formed, Rebuilding within EIP service, consisting of five subthemes: (i) Piecing together episode through talking to staff; (ii) Exploring other perspectives during CBT; (iii) Empowered through shared decision-making; (iv) Reconsidering future and purpose; (v) Service as safety-net. EIP provision was pivotal in helping participants understand their episode, adjust their perspective, build confidence and progress.

CONCLUSIONS

Aspects of the service that were valued, including person-centred relationships with staff, shared decision-making and the development of motivation and opportunities, reflect key principles of mental health care for young people following first episode psychosis. Furthermore, findings point to elements that may be particularly relevant to early intervention following first episode psychotic mania including managing mood escalation and individualised approaches to goals.

A realist review of medication optimisation of community dwelling service users with serious mental illness

BACKGROUND

Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI.

OBJECTIVE

Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community?

METHODS

A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations.

RESULTS

Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation.

CONCLUSIONS

Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers.

PROSPERO REGISTRATION NUMBER

CRD42021280980.

User-Centered Development of Bolster, an mHealth Intervention for Early Psychosis Caregivers: Needs Assessment, Prototyping, and Field Trial

BACKGROUND

Caregivers play a critical role in the treatment and recovery of youth and young adults at risk for psychosis. Caregivers often report feeling isolated, overwhelmed, and lacking in resources. Mobile health (mHealth) has the potential to provide scalable, accessible, and in-the-moment support to caregivers. To date, few if any mHealth resources have been developed specifically for this population.

OBJECTIVE

The aim of this study was to conduct user-centered design and testing of an mHealth intervention to support early psychosis caregivers.

METHODS

We conducted a multiphase user-centered development process to develop the Bolster mobile app. In phase 1, a total of 21 caregivers were recruited to participate in a qualitative needs assessment and respond to an initial prototype of the Bolster platform. Content analysis was used to identify key needs and design objectives, which guided the development of the Bolster mobile app. In phase 2, a total of 11 caregivers were recruited to participate in a 1-week field trial wherein they provided qualitative and quantitative feedback regarding the usability and acceptability of Bolster; in addition, they provided baseline and posttest assessments of the measures of distress, illness appraisals, and family communication.

RESULTS

In phase 1, participants identified psychoeducation, communication coaching, a guide to seeking services, and support for coping as areas to address. Live prototype interaction sessions led to multiple design objectives, including ensuring that messages from the platform were actionable and tailored to the caregiver experience, delivering messages in multiple modalities (eg, video and text), and eliminating a messaging-style interface. These conclusions were used to develop the final version of Bolster tested in the field trial. In phase 2, of the 11 caregivers, 10 (91%) reported that they would use Bolster if they had access to it and would recommend it to another caregiver. They also reported marked changes in their appraisals of illness (Cohen d=0.55-0.68), distress (Cohen d=1.77), and expressed emotion (Cohen d=0.52).

CONCLUSIONS

To our knowledge, this study is the first to design an mHealth intervention specifically for early psychosis caregivers. Preliminary data suggest that Bolster is usable, acceptable, and promising to improve key targets and outcomes. A future fully powered clinical trial will help determine whether mHealth can reduce caregiver burdens and increase engagement in services among individuals affected by psychosis.

' Like I said about culture. You don't talk about mental health' : An interpretative phenomenological analysis of the experience of first-episode psychosis in South Asian individuals

BACKGROUND

There is strong evidence of inequalities in mental healthcare access, experiences and outcomes for service users belonging to Black and Asian Minority Ethnic groups experiencing psychosis. Clinicians and academics have speculated that cultural variation in conceptualisations of psychosis, alongside inequitable service provision may explain disparities. There is, however, a dearth of literature exploring this in a South Asian population, despite this ethnic group being the second largest in the United Kingdom. The present study aimed to explore how people from this minority group have experienced and made sense of first-episode psychosis (FEP).

METHODS

A qualitative approach was used to explore the lived experience and sense-making of South Asian individuals experiencing FEP and accessing early intervention services. Eight people were interviewed using a semi-structured format. The data were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three superordinate themes were identified in the group analysis: (1) Disconnection from self and others (2) Doubt and dispute (3) Power and shame.

CONCLUSIONS

Distinctive ethnic, cultural and systemic influences were strongly evident in how people conceptualized their experiences, how they managed their sense-making and where they sought support. Experiences were discussed in the context of power and shame, and this research proposes that socio-cultural context and racialised discourses have an impact on self-concept, the experiences of help-seeking (formal and informal), and fundamentally how services help individuals from marginalized communities.

Show me you care: A patient- and family-reported measure of care experiences in early psychosis services

AIM

Despite their emphasis on engagement, there has been little research on patients' and families' experiences of care in early intervention services for psychosis. We sought to compare patients' and families' experiences of care in two similar early psychosis services in Montreal, Canada and Chennai, India. Because no patient- or family-reported experience measures had been used in a low- and middle-income context, we created a new measure, Show me you care. Here we present its development and psychometric properties.

METHODS

Show me you care was created based on the literature and stakeholder inputs. Its patient and family versions contain the same nine items (rated on a 7-point scale) about various supportive behaviours of treatment providers towards patients and families. Patients (N = 293) and families (N = 237) completed the measure in French/English in Montreal and Tamil/English in Chennai. Test-retest reliability, internal consistency, convergent validity, and ease of use were evaluated.

RESULTS

Test-retest reliability (intra-class correlation coefficients) ranged from excellent (0.95) to good (0.66) across the patient and family versions, in Montreal and Chennai, and in English, French, and Tamil. Internal consistency estimates (Cronbach's alphas) were excellent (≥0.87). The measure was reported to be easy to understand and complete.

CONCLUSION

Show me you care fills a gap between principles and practice by making engagement and collaboration as central to measurement in early intervention as it is to its philosophy. Having been co-designed and developed in three languages and tested in a low-and-middle-income and a high-income context, our tool has the potential for global application.

Retrospective Experiences of First-Episode Psychosis Treatment Under Open Dialogue-Based Services: A Qualitative Study

Open Dialogue (OD) is an integrated approach to mental health care, which has demonstrated promising outcomes in the treatment of first-episode psychosis (FEP) in Finnish Western Lapland region. However, little is known how treatment under OD is retrospectively experienced by the service users themselves. To address this, twenty participants from the original Western Lapland research cohort diagnosed with psychosis (F20-F29) were asked about their treatment of FEP, initiated under OD 10-23 years previously. Thematic analysis was used to explore how the treatment was experienced. Most participants viewed network treatment meetings as an important part of their treatment, as they enabled interactions with other people and the chance to go through difficult experiences. A minority of the participants had mixed experiences regarding family involvement and immediate home visits. OD may have the potential to promote therapeutic relationships, but replications from other catchment areas are needed.

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency

OBJECTIVES

Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery.

DESIGN

The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375).

METHOD

Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored.

RESULTS

Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult.

CONCLUSIONS

This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed.

PRACTITIONER POINTS

Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders

BACKGROUND

Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed.

OBJECTIVE

This study aimed to assess emerging adults' experiences of receiving treatment through FREED.

METHOD

This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically.

RESULTS

Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist.

CONCLUSION

This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.

"It means so much for me to have a choice": a qualitative study providing first-person perspectives on medication-free treatment in mental health care

BACKGROUND

In 2016, the Western Norway Regional Health Authority started to integrate more evidence-based psychosocial interventions into the existing mental health care, emphasizing the right for persons with psychosis to choose medication-free treatment. This change emerged from the debate on the effectiveness and adverse effects of the use of antipsychotic medication. Aspects beyond symptom reduction, such as interpersonal relationships, increased understanding of one's own pattern of suffering, hope and motivation, are all considered important for the personal recovery process.

METHODS

This study explores whether these aspects were present in users' descriptions of their recovery processes within the medication-free treatment programme in Bergen, Western Norway. We interviewed ten patients diagnosed with psychosis who were eligible for medication-free services about their treatment experiences. Data were analysed using Attride-Stirling's thematic network approach.

RESULTS

The findings show a global theme relating to personal recovery processes facilitated by the provision of more psychosocial treatment options, with three organizing subthemes: interpersonal relationships between patients and therapists, the patient's understanding of personal patterns of suffering, and personal motivation for self-agency in the recovery process. Participants described an improved relationship with therapists compared to previous experiences. Integrating more evidence-based psychosocial interventions into existing mental health services facilitated learning experiences regarding the choice of treatment, particularly the discontinuation of medication, and appeared to support participants' increased self-agency and motivation in their personal recovery processes.

CONCLUSION

Health care in Norway is perhaps one step closer to optimizing care for people with psychosis, allowing for more patient choice and improving the dialogue and hence the interpersonal relationship between the patient and the therapist. Personal patterns of suffering can be explored within a system aiming to support and have a higher level of acceptance for the discontinuation of medication. Such a system requires personal agency in the treatment regimen, with more focus on personal coping strategies and more personal responsibility for the recovery process.

Early Assessment and Support Alliance Connections: Community-Based Participatory Research to Develop a Peer-based Early Psychosis Web Resource with Young Adults

BACKGROUND

Young adults (YA) who have experienced early psychosis (EP) have valuable information about their recovery process yet are often left out of research.

OBJECTIVES

We used a community-based participatory research (CBPR) approach in partnership with the Early Assessment and Support Alliance (EASA) EP program and Portland State University to develop a peer-driven, webbased, recovery resource.

METHODS

We used our CBPR process to collaboratively develop the resource and conducted an iterative usability study to test and refine it.

LESSONS LEARNED

The resource was well-received and accessible. YA partners emphasize the importance of being prepared to learn about research and one's self, being open to new experiences, and how being co-researchers can help with processing EP experiences for the benefit of one's self and peers.

CONCLUSIONS

Peer involvement in intervention development may increase usability. It benefits YA and adult coresearchers. We strongly recommend including YA who have experienced EP as co-researchers.

Disengagement Processes Within an Early Intervention Service for First-Episode Psychosis: A Longitudinal, Qualitative, Multi-Perspective Study

BACKGROUND

Specialized early intervention services for first-episode psychosis have been well established in many countries to meet the unique needs of this group. However, with high drop-out rates, these services would benefit from understanding the factors that influence a person's decision to engage with, or disengage from, them. No research has explored the experiences of engagement and disengagement over time, from the perspectives of the person who experienced a first-episode psychosis, their caregiver, and their clinician. This information is crucial to help services better respond to the needs of the people using them. The aim of this study was to understand what causes and maintains periods of disengagement from early intervention services for first-episode psychosis over time.

METHODS

Using a longitudinal, qualitative approach, young people, their caregivers, and their clinicians were followed through their first year with an early intervention service for first-episode psychosis in Melbourne, Australia. Qualitative interviews were completed between 3-9 weeks, 4-7 months, and 11-15 months after entry to the service (or at discharge if earlier). Trajectory analysis was used to understand the data.

RESULTS

Qualitative interviews were conducted with 24 participants (55 interviews). Young people were aged 15-24 years, came from a variety of cultural backgrounds and had various psychotic diagnoses. Three major processes were identified that, over time, led to periods of service disengagement: a mismatch between service model and individual presentation (service mismatch), a lack of shared purpose (aimless engagement), and responses to individual circumstances (reactive disengagement).

CONCLUSION

Triangulating experiences of engagement across young people, caregivers, and clinicians allows for a comprehensive understanding of what precipitates service disengagement. This study demonstrates how early intervention services for first-episode psychosis are meeting the needs of young people and caregivers, and what areas warrant improvement. The needs of service users and patterns of disengagement vary. In turn, services must be flexible and responsive to individual circumstances. The results of this study recommend that local and international policies move away from diagnostically driven models of care, to better provide an inclusive treatment service for people with transdiagnostic mental health presentations.

Defining disengagement from mental health services for individuals experiencing first episode psychosis: a systematic review

BACKGROUND

Individuals affected by psychotic disorders frequently disengage from mental health services, although reports of this rate in the literature have ranged from 6 to 60%. One of the potential explanations for the large variation is that studies have adopted different definitions. Without a universal definition it is challenging to compare rates and factors leading to disengagement across studies. This systematic review aims to identify and compare how disengagement from psychosis services has been defined, measured and operationalised in the literature to date.

METHODS

A systemic literature search of the PubMed, PsycINFO and CINAHL databases was completed following the PRISMA guidelines for systematic reviews.

RESULTS

1506 Studies were identified, of which 30 were eligible to be included. It was found that disengagement was operationalized as either a categorical or continuous variable across studies, with 18 studies classifying it as a categorical, binary variable. Only four studies applied a time period over which disengagement was said to occur, and only four studies used an instrument to measure or predict disengagement. Few studies considered similar factors in their definition, when this occurred it was because the papers came from the same research group.

DISCUSSION

To truly understand the phenomenon of disengagement, studies need to have a comparable outcome variable. The need for consensus on a gold standard definition of disengagement that considers the full breadth of its complexity remains. A potential process for establishing a definition that includes set parameters, agreed upon terminology and time periods of assessment is discussed.

The missing voice of engagement: an exploratory study from the perspectives of case-managers at an early intervention service for first-episode psychosis

BACKGROUND

A key component of case-management in early intervention services for first-episode psychosis is engaging a person with the service and building a relationship from which therapy and treatment can be facilitated. The aim of this study was to understand how case-managers at an early intervention service experience the process of engagement and working with varying levels of attendance and participation.

METHODS

Qualitative interviews were conducted with the case-managers of nine young people treated at an early intervention service for first-episode psychosis within 6 months of treatment entry. Interviews discussed the process of working with the young person and factors that influenced service engagement. Interviews were analyzed using thematic analysis.

RESULTS

Case-managers described a range of influences on engagement which were grouped under the themes: young person and caregiver influences on engagement, case-manager influences on engagement, and influences of the early intervention service system on engagement. The experience of engagement was described as relational, however it occurred in the context of broader influences, some of which were unable to be changed or challenged by the case-manager (e.g., resource allocation, models of treatment, young person demographics).

CONCLUSION

This study illustrates the challenges that case-managers face when working with young people with first-episode psychosis, and the direct influence this has on engagement with treatment. Understanding these challenges and addressing them in policy and service design may lead to improvements in young peoples' recovery from first-episode psychosis and increase case-manager job satisfaction.

"Everyone Has a Role": Perspectives of Service Users With First-Episode Psychosis, Family Caregivers, Treatment Providers, and Policymakers on Responsibility for Supporting Individuals With Mental Health Problems

Varying perceptions of who should be responsible for supporting individuals with mental health problems may contribute to their needs remaining unmet. A qualitative descriptive design was used to explore these perceptions among key stakeholders. Focus groups were conducted with 13 service users, 12 family members, and 18 treatment providers from an early psychosis intervention program in Montreal, Canada. Individual interviews were conducted with six mental health policy-/decision-makers. Participants across stakeholder groups assigned a range of responsibilities to individuals with mental health problems, stakeholders in these individuals' immediate and extended social networks (e.g., families), macro-level stakeholders with influence (e.g., government), and society as a whole. Perceived failings of the health care system and the need for greater sharing of roles and responsibilities also emerged as important themes. Our findings suggest that different stakeholders should collectively assume certain responsibilities and that systems-level failings may contribute to unmet needs for mental health support.

Living With an Intestinal Stoma: A Qualitative Systematic Review

The main aim of this article is to explore the experiences and life situations of people living with intestinal stomas. Previous studies indicated the need to investigate the concerns of ostomy patients and how these concerns can affect their quality of life and their approaches to the comprehensive conceptualization of the bodily changes. A qualitative systematic review and metasynthesis design was carried out by using the main scientific databases. Original articles from 2002 to 2015 were selected based on their qualitative methodology. Methodological quality was evaluated using the Critical Appraisal Skills Program. The findings were synthesized using the metasynthesis procedure of Sandelowski. The final number of articles included was 95 and 1,982 participants. Regarding the metasummary, the data generated 191 thematic statements that were organized into eight categories. The findings support an explanatory model of the experience of people with ostomy based on three aspects: Acceptance, Adaptation, and Autonomy.

"We all have a responsibility": a narrative discourse analysis of an information campaign targeting help-seeking in first episode psychosis

BACKGROUND

Intervening at an early stage of psychosis improves the chances of recovery from first-episode psychosis. However, people who are experiencing distress and early psychotic symptoms generally seem to delay seeking help. Therefore, multifaced information campaigns targeting help-seeking behavior of potential patients and their network are considered important tools within early detection and intervention strategies. In this study, we aimed to explore which discursive meaning content, including roles and actors, such information campaigns build on and construct. Our intention was not to provide objective answers, but to contribute to a discursive debate about potential conflicts in messages conveyed in such campaigns.

METHODS

A broad sample of information material utilized by TIPS Stavanger University Hospital (Norway) was examined. The material consisted of posters, booklets and brochures, newspaper ads, Facebook ads, and TIPS Info's website, representing various campaigns from 1996 to April 2018. A narrative discursive approach was applied at an epistemological level. At a practical level, a team-based thematic analysis was utilized to identify patterns across data.

RESULTS

Diversity and several changes in strategy were recognized throughout the information material. Furthermore, three main themes and four subthemes were found to constitute the meaning content built in the information campaigns: knowledge is key; (almost) an illness among illnesses; and we all have a responsibility (comprising of the subthemes; to respond quickly; to step in; to provide an answer; and to tag along).

CONCLUSION

Our findings pointed to common dilemmas in mental health services: How to combine professional expert knowledge with collaborative practices that emphasize shared decision-making and active roles on behalf of patients? How to combine a focus on symptoms and illness and simultaneously express the importance of addressing patients' recourses? And how can we ask for societal responsibility in help-seeking when professionals are placed in expert positions which may not be optimal for dialogue with potential patients or their network? We discuss whether highlighting practices with more weight on resources and active roles for patients and their surroundings in information campaigns could promote earlier help-seeking.

Moving Toward Connectedness - A Qualitative Study of Recovery Processes for People With Borderline Personality Disorder

Borderline personality disorder (BPD) is a mental health disorder estimated to affect 1–2% of the general population. As a group, people with BPD endure a high degree of suffering, often leading to suicide attempts, self-harm, and suicide. Comparatively few studies explore the first person perspective of the person suffering from any mental health disorder. This might be especially problematic for people diagnosed with BPD, as this particular diagnosis is followed by stigma potentially making help seeking harder and helping relationships more vulnerable. We interviewed 12 female participants recently diagnosed with BPD in-depth about their experiences with recovery and treatment, and used a stepwise reflective approach to rigorously analyze the data. Results show an overarching theme of working toward connectedness, with four constituent sub-themes. We discuss the findings with regard to empirical work, recovery and autonomy, and the risk of epistemic injustice that people with BPD risk facing.

Sources of Distress in First-Episode Psychosis: A Systematic Review and Qualitative Metasynthesis

In this study, we aim to increase our understanding of the self-reported sources of distress among people who have experienced first-episode psychosis. Following a systematic literature search, 33 relevant studies containing first-person accounts of first-episode psychosis were identified, which were synthesized using thematic analysis. Two interrelated superordinate themes were identified: intrapersonal distress and interpersonal distress. Participants reported multiple, diverse, and multifaceted sources of distress across both themes. These were substantially different from those routinely recognized and targeted in clinical practice. This review suggests that practitioners who maintain a stance of genuine curiosity about the potential sources of distress for this population will be perceived as more helpful. The findings also highlight the importance of being service user-led when planning and delivering mental health care. Additional clinical and research implications are discussed.

Health Practitioners' Perceptions of Falls and Fall Prevention in Older People: A Metasynthesis

Fall prevention has received a great deal of consideration and funding, however fall rates have not reduced accordingly. Health practitioners are key stakeholders in the process of implementing fall prevention evidence into their clinical assessment and management of older people at risk of falling. Investigating health practitioners' clinical experiences and perceptions has been identified as a means to enhance the translation of knowledge. Four databases were searched for studies exploring health practitioners' perceptions of falls and fall prevention. A metasynthesis of eight qualitative studies was conducted. The findings suggest that health practitioners face substantial barriers in the implementation of fall prevention practices. These include personal, interpersonal, and clinical barriers in addition to limitations of the research evidence. This knowledge hopes to enhance targeted dissemination of knowledge, reducing the research-practice gap and improving clinical outcomes for older people at risk of falls.

The Duration of Untreated Psychosis: A Phenomenological Study

Mounting evidence has indicated that early intervention leads to improved clinical and functional outcomes for young persons experiencing recent onset psychosis. As part of a large early detection campaign, the present study aimed to investigate subjective experiences during the duration of untreated psychosis (DUP), or time between psychosis onset and treatment contact. Participants were 10 young adults participating in early intervention services for psychosis. After DUP was estimated during standardized baseline assessment, participants engaged in qualitative interviews focused on their life experiences prior to treatment and leading up to the present. Mixed methods data analyses compared standardized DUP estimates with participants' subjective narratives. Findings revealed that participants experienced and conceptualized a longer trajectory of subjective difficulties (TSD) beginning before and extending beyond standardized DUP estimates. Participants emphasized striving for independence and social belonging. The majority of participants reported benefiting from their current services and believed that earlier support of some kind would have been beneficial. These findings support previous research on subjective barriers to early detection and treatment seeking in young adults experiencing psychosis. Implications and future research directions include further efforts to differentiate the struggles unique to early psychosis from psychosocial risk factors and other challenges of young adulthood.

Career Decision-Making Processes of Young Adults With First-Episode Psychosis

The first episode of psychosis often emerges during young adulthood, when individuals are pursuing important educational and career goals that can become derailed because of the development of major impairments. Past research has neglected the developmental nature of employment and education decisions that young adults with first-episode psychosis make within the context of their lives. The purpose of this grounded theory study was to advance a model of the career decision-making processes of young adults with first-episode psychosis, and the influences that affect their career decision-making. The career decision-making of young adults with first-episode psychosis emerged as a multistaged, iterative process that unfolded over three phases of illness, and was affected by several internal and environmental influences. These findings suggest the phase of illness and career decision-making stage should be considered in future vocational programming for young adults with first-episode psychosis.