Severe and enduring mental health problems within an established substance misuse treatment partnership

Caregivers' experiences in helping individuals with severe and enduring mental health challenges integrate into the community: A qualitative descriptive study in Singapore

WHAT IS KNOWN ABOUT THE SUBJECT

Individuals with severe and enduring mental health challenges continued to consume mental health services for an average of 13 years as they needed multiple acute psychiatric admissions due to the challenges they experienced in their everyday activities. As caregivers of individuals with severe and enduring mental health challenges, they often bear the brunt of caregiving through their assistance with activities of daily living (ADL), providing emotional support and ensuring medication compliance for their loved ones. When caring for their loved ones, caregivers often reported psychological stress, social isolation and emotional exhaustion due to stressors such as uncertainty of the future, the lack of support from professional services and the isolation from their own social network and support mechanism.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Insights from this study revealed that caregivers for individuals with severe and enduring mental health challenges went through a lonely and exhausting journey fraught with psychological, physical, social and financial challenges, echoing the caregiving needs and the prevalence of the caregiver burden.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Insights shared by the caregivers demonstrated the need for a centralised point of contact to navigate Singapore's fragmented mental healthcare sector. Peer-support groups should be further promoted because they offer the benefits of information exchange, mutual support and a sense of empowerment and hopefulness, which may help ease the caregiver burden. Life skills training, such as teaching how to communicate empathetically with family members, resolve conflicts using open communication, maintain a structured daily routine and solve pragmatic problems in daily life, is more critical for individuals with severe and enduring mental health challenges. This will help them learn how to manage their well-being, live independently, and stabilise their conditions. Lastly, public awareness campaigns should honour caregivers by highlighting their strength, resilience, and dedication. The state can provide financial assistance in the form of tax relief for their income per annum or caregiver allowance to alleviate the financial stress that caregivers are facing.

ABSTRACT

Introduction The progressive deinstitutionalisation of mental healthcare has increasingly shifted care responsibilities from healthcare professionals to family caregivers for individuals with severe mental illness. Caregivers must balance many obligations, which often compromise their overall health and well-being, while helping their loved ones integrate into the community. Aim To identify and understand caregivers' needs and challenges as they help individuals with severe and enduring mental health challenges integrate into the community. Methods This study used a descriptive qualitative approach to explore the experiences and challenges of caregivers for individuals with severe and enduring mental health challenges when integrating back into the community. A semi-structured guide was used during the video-conferencing interviews conducted between December 2021 and November 2022. This study was reported according to the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Findings Fourteen caregivers were individually interviewed by the primary author. Most caregivers were female, with an average of 15 years of experience caring for their loved ones. Using Braun and Clark's six-phase thematic framework, we inductively generate the themes and subthemes from the data. The two themes were (i) challenges (whose subthemes included personal challenges in caregiving, the lack of awareness, and stigma and employment) and (ii) support (whose subthemes included the importance of socialisation for individuals with mental health conditions, existing avenues of support and potential areas for support). Discussion Our findings informed the contemporary needs of caregivers caring for individuals with severe and enduring mental health challenges integrating into the community. Like the global challenges for people with mental health issues, psychosocial support and other supplementary support are still common themes in mental health settings. The findings further specifically highlighted the importance of accessible points of contact as resources and employment-enabling and sustaining initiatives to help manage caregivers' emotional and system challenges, which addresses the gaps identified in the findings. Caregivers' peer-support groups, life skills training and public mental health awareness are also necessitated by the caregivers' voices. Implications for Practice Priority areas include having a centralised point of contact within the community for caregivers. Government or not-for-profit organisations can take the lead by initiating employment-enabling initiatives for individuals with severe and enduring mental health challenges and their caregivers.

Effects of peer-delivered self-management, recovery education interventions for individuals with severe and enduring mental health challenges: A meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: The paradigm shifts in the conceptualization of recovery have led to a wide adoption of peer-delivered self-management interventions among individuals with severe and enduring mental health challenges. Peers with experiential knowledge on managing their own mental health conditions act as role models for affected individuals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The meta-analysis demonstrated significant small-to-medium effects favouring such interventions on symptom severity, self-perceived recovery, hopefulness and empowerment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With peer-delivered self-management interventions, individuals with severe and enduring mental health challenges could self-direct their care, thus reducing their reliance on service providers. Individuals with severe and enduring mental health challenges equipped to seek their recovery within the community beyond institutional care, regaining independence and gradually reintegrate into society. ABSTRACT: Introduction The shift in mindset within mental health care has led to the adoption of peer-delivered self-management interventions in promoting recovery among individuals with severe and enduring mental health challenges. However, no reviews have hitherto examined their effectiveness. Aim To determine the effectiveness of peer-delivered self-management interventions in improving symptom severity, self-perceived recovery, hopefulness and empowerment. Method A search was performed in nine English databases for published studies and grey literature from inception to the 5 January 2021. The methodological quality of the studies was graded with the Joanna Briggs Institute's critical appraisal tools. The overall effects were pooled through a meta-analysis with heterogeneity evaluated via the chi-square test and I-square statistics. This review was guided by the PRISMA 2020 statement on transparent reporting of systematic review and meta-analyses. Results Seventeen publications involving 3189 participants were included in this review, and ten were included for the meta-analysis and accounted for 2725 participants. The meta-analysis demonstrated significant small-to-medium effects favouring such interventions on symptom severity, self-perceived recovery, hopefulness and empowerment. Discussion Peer-delivered self-management interventions should be implemented as it is effective in promoting recovery among individuals with severe and enduring mental health challenges. Implications for practice With peer-delivered self-management interventions, individuals with severe and enduring mental health challenges could self-direct their care and reduce their reliance on service providers.

Multiple Morbidities in an Inner-City English Substance Misuse Treatment Service: Hierarchical Cluster Analysis to Derive Treatment Segments

Comorbid needs of people attending substance use treatment has been well documented although there is an assumption of heterogeneity in the treated population. This study utilized hierarchical cluster analysis to explore the extent and nature of client segments within the treated population. Methods: A retrospective review of comorbid health and social needs of a random sample of client case-notes (n = 300) was undertaken on all people known to treatment in an urban, inner-London community out-patient treatment service during 2018-2019. A hierarchical cluster analysis using Ward's linkage method was implemented to explore the data to determine and describe emergent clusters. Inter cluster differences were investigated further by modeling methods. Results: High rates of physical health (63%) and mental health (50%) need were noted across the entire treatment population. The hierarchical clustering identified three discrete segments of the treatment population. The largest segment (46% of clients) was complex, socially impacted chaotic heroin and crack misusers exhibiting a wide range of multiple morbidities including social needs such as housing, unemployment and offending. This cluster also were more likely to report acute needs such as Emergency Department attendance, utilization of ambulatory services and will and episodic disengagement disengage episodically from treatment. A second segment (24% of clients) exhibited similar drug using profiles to the largest cluster, although with fewer comorbid issues. This cluster tended to be older and more likely to report respiratory conditions. A third cluster (25% of clients) was more likely to be alcohol misusers who were new to treatment. Conclusions: Treated populations are likely to be relatively heterogeneous across a range of social harms, physical and mental health needs. Identifying multidimensional needs of segments within treatment services allows for the creation of tailored treatment interventions.

Prescribers' views and experiences of assessing the appropriateness of prescribed medications in a specialist addiction service

Background Mental and physical health problems are common in people with substance misuse problems and medications are often required in their management. Given the extent of prescribing for service users who attend specialist addiction services, it is important to consider how prescribers in this setting assess the appropriateness of service users’ prescribed medications. Objective To explore prescribers’ views and experiences of assessing the appropriateness of medications prescribed for service users coming in for treatment as well as the differences between prescribers. Setting A specialist addiction service in the North of England. Method A phenomenological approach was adopted. Semi-structured interviews were conducted with four nurse prescribers and eight doctors. Data were analysed using thematic framework analysis. Main outcome measure Prescribers’ views and experiences of assessing the appropriateness of prescribed medications. Results Assessment of the appropriateness of prescribed medications involved reviewing medications, assessing risk, history-taking, involvement of service users, and comparing guideline adherence and ‘successful’ prescribing. Doctors and nurse prescribers assessed the appropriateness of medications they considered to be within their competency. Doctors provided support to nurse prescribers and general practitioners (GPs) when dealing with issues around prescribing. Conclusion Assessment of the appropriateness of prescribed medications is complex. The recent reduction in medical expertise in specialist addiction services may negatively impact on the clinical management of service users. It appears that there is a need for further training of nurse prescribers and GPs so they can provide optimal care to service users.