Patient oriented research in mental health: matching laboratory to life and beyond in Canada

Lived experience-informed eating disorders research: an illustrative example

The mental health field, and more recently, the eating disorders field specifically, has witnessed a paradigm shift towards collaborative research which is conducted in partnership with individuals possessing lived and living experiences of mental health conditions (i.e. those with personal lived or living experience and those who are family, carers, or other supports). However, despite this shift, the challenge of engaging individuals with lived experiences in a manner that avoids tokenism, manages power imbalances, and ensures meaningful involvement persists. This paper aims to encourage those working in the eating disorders field to establish authentic, equitable partnerships with lived experience contributors. To provide clarity and to encourage researchers to engage in effective and authentic lived experience collaborations, this paper describes different types of lived experience involvement in research, using real-life examples from a study that is currently being established.

Best Practices Guidelines for the Engagement of People With Lived Experience and Family Members in Mental Health and Substance Use Health Research: A Modified Delphi Consensus Study

INTRODUCTION

People with lived experience of mental health and/or substance use conditions and their families (PWLE) are increasingly engaged in research, yet rigorous guidelines for engagement are lacking. This study aims to co-design best practice guidelines to support the authentic, meaningful engagement of PWLE in mental health and/or substance use health research.

METHODS

A multi-panel modified Delphi study was conducted with 61 expert panelists (35 PWLE and family members, 26 researchers/research support staff from across Canada). Participants rated 56 recommendations for importance and clarity. Consensus was defined as ≥ 70% of participants rating items at 6 or 7 on a 7-point Likert scale ('very important' or 'essential'). Qualitative feedback was analysed using content analysis to identify new items and reviewed for improvements in item clarity. After each round, items not meeting the established threshold of importance were removed. Items with low clarity scores were reworded. A PWLE advisory panel was actively involved throughout the study's design, implementation, interpretation, and reporting, ensuring that the perspectives of people with lived experience were integrated throughout the research process.

RESULTS

Three Delphi Rounds were conducted. In Round 1, importance ratings ranged from 51.7% to 96.7% of participants ranking the items above the established threshold (average 80.1%), with clarity ratings ranging from 39.3% to 86.9% (average 70.7%) and an average importance coefficient of variation (CV) of 0.16. Four items were deleted, two new items were added and fifty-five items were revised. In Round 2, 60 (98.4%) participants responded. Importance ratings ranged from 57.6% to 96.7% (average 80.2%; average CV = 0.20). Clarity ratings ranged from 50.9% to 93.2% (average 77.9%). Five items were deleted and eleven revised. In Round 3, 60 (98.4%) participants provided importance ratings ranging from 66.7% to 98.3% (average 80.8%; average CV = 0.20), and clarity ratings ranging from 63.3% to 94.9% (average 81.1%). Three items were deleted and nine were revised. Forty-four final best practices are proposed.

CONCLUSION

These co-developed best practice guidelines offer recommendations for meaningful PWLE engagement in mental health and/or substance use health research. By following these guidelines, research teams can ensure that PWLE contributions are genuinely valued and effectively integrated, ultimately enhancing the quality and impact of the research and fostering authentic collaboration.

PATIENT AND PUBLIC INVOLVEMENT

People with lived experience were engaged throughout the project as key team members, from a patient-oriented research perspective. They are also co-authors on this manuscript.

An in-depth understanding of stakeholders' experiences about their participation in the co-production of 'Maze Out': a serious game for the treatment of eating disorders

BACKGROUND

Co-production is increasingly used in mental health research and clinical settings. Maze Out is a digital game co-produced by clinicians, patients with eating disorders (EDs), an art director with lived experience in EDs, and a game-developing company. Maze Out is based on everyday challenges when suffering from EDs and is currently being evaluated as a supplement tool in EDs treatment. Several studies on co-producing mental health interventions focus on design and effectiveness, but the experiences of those involved in the co-production process remain unexplored. An in-depth exploration of stakeholders' experiences offers valuable insights into the impact of co-production on different groups and generates crucial knowledge for successful implementation.

OBJECTIVES

This study evaluated and explored the co-production process and the meaning that EDs patients, clinicians, and game designers attributed to their participation in the co-production of Maze Out. The objectives were to determine (1) how stakeholders experienced their collaboration in the co-production of Maze Out.; and (2) to what extent the stakeholders involved in developing Maze Out followed Cahn's principles of equality, diversity, accessibility, and reciprocity.

METHODS

Five stakeholders (two patients, two clinicians, and a game designer) who participated in the co-production completed semi-structured interviews. Two patients and one clinician's diaries supplemented the interviews. Reflexive thematic analysis was used to interpret the data.

RESULTS

The results of this study highlight the importance of building a common language between clinicians, patients, and other professionals involved in developing new forms of treatment and interventions. A recommendation for researchers and clinicians to implement co-production in the future is that Cahn's principles: equality, reciprocity, accessibility, and diversity, serve as a strong foundation for successful co-production. In this study, three and partially one of the four Cahn's principles about co-production were identified: equality, reciprocity, and accessibility. When applied in an ED context, these principles provided stakeholders with valuable insights, enriching practice-based knowledge, using the knowledge applicable to clinical practice, and demonstrating their crucial role in fostering effective co-production processes.

Engagement of people with lived experience in studies published in high-impact psychiatry journals: meta-research review

BACKGROUND

We evaluated studies published in high-impact psychiatry journals to assess (1) the proportion that reported in articles whether they engaged people with lived experience; (2) the proportion that likely engaged people with lived experience; and, if engagement occurred, (3) stages of research (planning, conduct, interpretation, dissemination); and (4) engagement level (consult, involve, partner).

METHODS

We searched PubMed on December 14, 2022, for articles in psychiatry journals with impact factor ≥ 10 and reviewed articles in reverse chronological order until 141 were included, based on pre-study precision estimation. We contacted authors to obtain information on engagement.

RESULTS

Three of 141 (2%) studies reported engagement of people with lived experience in articles. Of the other 138 studies, 74 authors responded to follow-up emails and 22 reported they engaged people with lived experience but did not report in the article. Depending on assumptions about engagement by non-responders, we estimated, overall, 18-31% of studies may have engaged people with lived experience. Engagement occurred in research planning (70%) and rarely interpretation (35%). Most involved consultation (providing opinions or perspectives, 53%) and few involved partnership (11%).

CONCLUSIONS

Engagement of people with lived experience in psychiatry research is uncommon, and when it does occur people are typically consulted but not engaged in roles with influence on decision-making. Funding agencies, ethics committees, journals, and academic institutions should take steps to support engagement of people with lived experience in psychiatry research.

Engaging diverse patients in a diverse world: the development and preliminary evaluation of educational modules to support diversity in patient engagement research

BACKGROUND

Current practices for engaging patients in patient-oriented research (POR) result in a narrow pool of patient perspectives being reflected in POR. This project aims to address gaps in methodological knowledge to foster diversity in POR, through the co-design and evaluation of a series of educational modules for health researchers in British Columbia, Canada.

METHODS

Modules were co-created by a team of academic researchers and patient partners from hardly-reached communities. The modules are presented using the Tapestry Tool, an interactive, online educational platform. Our evaluation framework focused on engagement, content quality, and predicted behavior change. The User Engagement Scale short form (UES-SF) measured participants' level of engagement with the modules. Survey evaluation items assessed the content within the modules and participants' perceptions of how the modules will impact their behavior. Evaluation items modeled on the theory of planned behavior, administered before and after viewing the modules, assessed the impact of the modules on participants' perceptions of diversity in POR.

RESULTS

Seventy-four health researchers evaluated the modules. Researchers' engagement and ratings of module content were high. Subjective behavioral control over fostering diversity in POR increased significantly after viewing the modules.

CONCLUSIONS

Our results suggest the modules may be an engaging way to provide health researchers with tools and knowledge to increase diversity in health research. Future studies are needed to investigate best practices for engaging with communities not represented in this pilot project, such as children and youth, Indigenous Peoples, and Black communities. While educational interventions represent one route to increasing diversity in POR, individual efforts must occur in tandem with high-level changes that address systemic barriers to engagement.

Research evidence and implementation gaps in the engagement of people with lived experience in mental health and substance use research: a scoping review

BACKGROUND

There is growing recognition that engaging people with lived experience (PWLE) in mental health and substance use research improves the quality of the research in terms of relevance to the population and the feasibility of the work. Engagement also provides positive opportunities for research teams and the PWLE engaged. However, there are many gaps in the research on PWLE engagement. This scoping review synthesizes the gaps in the implementation of PWLE engagement and in the research on engagement as presented by research teams engaging PWLE in their work.

METHOD

A systematic electronic database search was conducted in 2022 for published articles on PWLE engagement in mental health and substance use research. Potential articles were screened for relevance. The search led to 49 final articles included in the review. The 49 articles were then coded using codebook thematic analysis to answer two research questions: (1) What are the research evidence gaps regarding the engagement of PWLE in mental health and substance use research?; and (2) What are the gaps in implementing PWLE engagement in mental health and substance use research? PWLE were engaged in the conduct of this review.

RESULTS

Results showed that research evidence gaps include further work on conceptualizing engagement; developing resources, tools, and practice recommendations to support research teams; increasing diversity in evaluations of engagement; and evaluating engagement, including its impact on the research, on PWLE, and on researchers. Implementation gaps included several broader institutional gaps and gaps in the day-to-day practice of engagement.

CONCLUSIONS

Despite progress in PWLE engagement in mental health and substance use research in recent years, research evidence and implementation gaps remain. Research teams are encouraged to consider these gaps and conduct research and implementation activities to address them in a rigorous manner.

Co-learning commentary: a patient partner perspective in mental health care research

BACKGROUND

Although including patients as full, active members of research teams is becoming more common, there are few accounts about how to do so successfully, and almost none of these are written by patient partners themselves. Three patient partners contributed their lived experience to a three-year, multi-component mental health research project in British Columbia, Canada. As patient partners, we contributed to innovative co-learning in this project, resulting in mutual respect and wide-ranging benefits. To guide future patient partners and researchers seeking patient engagement, we outline the processes that helped our research team 'get it right'.

MAIN BODY

From the outset, we were integrated into components of the project that we chose: thematically coding a rapid review, developing questions and engagement processes for focus groups, and shaping an economic model. Our level of engagement in each component was determined by us. Additionally, we catalyzed the use of surveys to evaluate our engagement and the perceptions of patient engagement from the wider team. At our request, we had a standing place on each monthly meeting agenda. Importantly, we broke new ground when we moved the team from using previously accepted psychiatric terminology that no longer fit the reality of patients' experiences. We worked diligently with the team to represent the reality that was appropriate for all parties. The approach taken in this project led to meaningful and successfully integrated patient experiences, fostered a shared understanding, which positively impacted team development and cohesion. The resulting 'lessons learned' included engaging early, often, and with respect; carving out and creating a safe place, free from stigma; building trust within the research team; drawing on lived experience; co-creating acceptable terminology; and cultivating inclusivity throughout the entire study.

CONCLUSION

We believe that lived experience can and should go hand-in-hand with research, to ensure study outcomes reflect the knowledge of patients themselves. We were willing to share the truth of our lived experience. We were treated as co-researchers. Successful engagement came from the 'lessons learned' that can be used by other teams who wish to engage patient partners in health research.

Meeting in the middle: experiences of citizenship in community-engaged psychosis research

Purpose

Previous research has highlighted the importance of engaging people with lived experience (PWLE) in the knowledge creation process. However, diverse approaches to engagement exist. In addition, tensions remain in community-engaged research (CER), including how to address structural inequalities in research settings. This study aims to consider how CER interacts with citizenship within and beyond the research context.

Design/methodology/approach

This study discusses the authors’ experiences as a majority-PWLE of psychosis research team in Canada, including successes and challenges the authors experienced building their team and navigating research institutions. This study also reflects on the authors’ pathways through citizenship, prior to and during the research process. This study discusses divergent models of CER and their applicability to the cyclical process of citizenship and community participation.

Findings

Relationships between academic and peer researchers developed organically over time. However, this study was limited by structural barriers such as pay inequality and access to funding. The authors recognize that there are barriers to full citizenship and acknowledge their resources and privilege of being well supported within their communities. Team members built on a foundation of citizenship to access participation in research. This led to opportunities to engage in community spaces, and for PWLE to participate in research as partners and leaders. This study also found that citizenship is a way of giving back, by building a sense of social responsibility.

Originality/value

Academic and peer researchers can reflect on the authors’ experiences to build more inclusive research teams and communities by using a citizenship approach to research participation.

The shiny new object: Deconstructing the patient-oriented paradigm in health sciences

RATIONALE

A 'patient-oriented' research paradigm, also known as patient and public engagement, has infiltrated the field of health sciences and continues to spread. At first blush, it is difficult to reprove anything labelled 'patient-oriented'; however, the patient-oriented paradigm may easily become an ideological 'good', leading to unintended consequences that may well prove more detrimental than beneficial. While patient-oriented research has its roots in more radical forms of patient and public engagement, its recent instantiation betrays its roots and forecloses on more radical forms of engagement, such as critical participatory research.

AIM AND OBJECTIVES

The objective of this article is to deconstruct the patient-oriented research narrative and to demonstrate how such a discourse imposes itself as a dominant approach in health sciences.

APPROACH

Following Derrida's deconstructive approach, we bring to light the unexamined presuppositions, false pretences, and presumed 'goodness' and 'naturalness' of patient-oriented discourse.

DISCUSSION

By deconstructing the patient-oriented narrative we demonstrate how pre-existing power structures (biomedical, economic, etc.) shape the conduct of the approach and serve to depoliticize the truly participatory aspects of research. Rather than being modelled on the evidence-based movement or seen as its natural 'evolution', patient-oriented research should resist by affirming itself as a radical form that is both participatory and emancipatory.

Considerations for supporting meaningful stakeholder engagement in global mental health research

The need to ensure that research evidence is adopted by health systems and is informed by lived experience expertise has been increasingly recognised in mental health research. In the field of global mental health (GMH), though some progress has been made, the meaningful engagement of key stakeholders in research remains low. This editorial outlines recommendations to support the meaningful engagement of policy makers and people with lived or living experience of mental illness in GMH research. Recommendations include: increasing funding structures that are designed to support meaningful engagement; urging institutions to consider administrative structures that support engagement with lower resourced partners; promoting capacity development opportunities and resources to support researchers to promote meaningful engagement; developing research governance structures that include key stakeholders; and, taking steps to ensure the needs of diverse stakeholders are met through their engagement in research. Examples of good practice from these areas are provided. Though not an exhaustive list of recommendations, this editorial represents a call to the GMH research community to take a deliberate and proactive approach to prioritising meaningful stakeholder engagement in GMH research with the ultimate goal of improving accessible and appropriate mental health care.

Automatic Diagnosis of Mental Healthcare Information Actionability: Developing Binary Classifiers

We aimed to develop a quantitative instrument to assist with the automatic evaluation of the actionability of mental healthcare information. We collected and classified two large sets of mental health information from certified mental health websites: generic and patient-specific mental healthcare information. We compared the performance of the optimised classifier with popular readability tools and non-optimised classifiers in predicting mental health information of high actionability for people with mental disorders. sensitivity of the classifier using both semantic and structural features as variables achieved statistically higher than that of the binary classifier using either semantic (p < 0.001) or structural features (p = 0.0010). The specificity of the optimized classifier was statistically higher than that of the classifier using structural variables (p = 0.002) and the classifier using semantic variables (p = 0.001). Differences in specificity between the full-variable classifier and the optimised classifier were statistically insignificant (p = 0.687). These findings suggest the optimised classifier using as few as 19 semantic-structural variables was the best-performing classifier. By combining insights of linguistics and statistical analyses, we effectively increased the interpretability and the diagnostic utility of the binary classifiers to guide the development, evaluation of the actionability and usability of mental healthcare information.