What Patients With Severe Mental Illness Transitioning From Hospital to Community Have to Say About Care and Shared Decision-Making

Transitional care programs to improve the post-discharge experience of patients with multiple chronic conditions and co-occurring serious mental illness: A scoping review

The transition from hospital to home can be especially challenging for those with multiple chronic conditions and co-occurring serious mental illness (SMI). This population tends to be Medicaid-insured and disproportionately experiences health-related social needs. The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. A scoping review was conducted using Arksey and O'Malley's methodology. Three databases were searched; ten articles describing eight transitional care programs published from 2013 to 2024 met eligibility criteria. Five programs focused on patients being discharged from a psychiatric admission. Five of the interventions were delivered in the home. Intervention components included coaching services, medication management, psychiatric providers, and counseling. Program lengths ranged from one month to 90 days post-hospitalization. These programs evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Notably, few programs appeared to directly address the unmet social needs of participants. While the focus and components of each transitional care program varied, there were overall positive improvements for participants in terms of improved quality of life, increased share decision making, and connections to primary and specialty care providers.

Patient-related characteristics considered to affect patient involvement in shared decision making about treatment: A scoping review of the qualitative literature

OBJECTIVE

To identify patient-related characteristics considered to affect patient involvement in shared decision making (SDM) about treatment.

METHODS

We conducted a scoping review of qualitative studies. We searched for literature across seven databases until March 2022, and included qualitative studies that focused on associations between patient-related characteristics and SDM about treatment in adults. We analyzed studies using an inductive thematic approach.

RESULTS

The search yielded 5948 articles, of which 70 were included. We identified many different patient-related characteristics, which we grouped into four categories related to: (1) the individual who is facing the decision, (2) the decision, (3) the relationship between the patient and the clinician and others involved in the decision, and (4) the healthcare context.

CONCLUSIONS

Studies report a variety of patient-related characteristics that may affect patient involvement in SDM. Amongst others, patients may need to feel informed, to understand their role in SDM, and be able to communicate. Involvement may be challenging with characteristics such as perceived time pressure, poor patient-clinician relationships, emotional distress, and severe illness.

PRACTICE IMPLICATIONS

In order to truly involve patients in SDM, we might need to focus on characteristics such as patient emotions and relationship building, besides information provision and values clarification.

An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders

BACKGROUND

Antipsychotic medication can reduce psychotic symptoms and risk of relapse in people with schizophrenia and related disorders, but it is not always effective and adverse effects can be significant. We know little of patients' views about continuing or discontinuing antipsychotic treatment.

AIMS

To explore the views of people with schizophrenia and other psychotic disorders about continuing their antipsychotic medication or attempting to reduce or discontinue this medication with clinical support.

METHODS

We collected quantitative and qualitative data by conducting semi-structured interviews in London, UK. Factors predicting a desire to discontinue medication were explored. Content analysis of qualitative data was undertaken.

RESULTS

We interviewed 269 participants. 33% (95% CI, 27 to 39%) were content with taking long-term antipsychotic medication. Others reported they took it reluctantly (19%), accepted it on a temporary basis (24%) or actively disliked it (18%). 31% (95% CI, 25 to 37%) said they would like to try to stop medication with professional support, and 45% (95% CI, 39 to 51%) wanted the opportunity to reduce medication. People who wanted to discontinue had more negative attitudes towards the medication but were otherwise similar to other participants. Wanting to stop or reduce medication was motivated mainly by adverse effects and health concerns. Professional support was identified as potentially helpful to achieve reduction.

CONCLUSIONS

This large study reveals that patients are commonly unhappy about the idea of taking antipsychotics on a continuing or life-long basis. Professional support for people who want to try to reduce or stop medication is valued.

Shared decision making for adults with severe mental illness: A concept analysis

AIM

Shared decision making for adults with severe mental illness has increasingly attracted attention. However, this concept has not been comprehensively clarified. This review aimed to clarify a concept of shared decision making for adults with severe mental illness such as schizophrenia, depression, and bipolar disorder, and propose an adequate definition.

METHODS

Rodgers' evolutionary concept analysis was used. MEDLINE, PsychINFO, and CINAHL were searched for articles written in English and published between 2010 and November 2019. The search terms were "psychiatr*" or "mental" or "schizophren*" or "depression" or "bipolar disorder", combined with "shared decision making". In total, 70 articles met the inclusion criteria. An inductive approach was used to identify themes and sub-themes related to shared decision making for adults with severe mental illness. Surrogate terms and a definition of the concept were also described.

RESULTS

Four key attributes were identified: user-professional relationship, communication process, user-friendly visualization, and broader stakeholder approach. Communication process was the densest attribute, which consisted of five phases: goal sharing, information sharing, deliberation, mutual agreement, and follow-up. The antecedents as prominent predisposing factors were long-term complex illness, power imbalance, global trend, users' desire, concerns, and stigma. The consequences included decision-related outcomes, users' changes, professionals' changes, and enhanced relationship.

CONCLUSIONS

Shared decision making for adults with severe mental illness is a communication process, involving both user-friendly visualization techniques and broader stakeholders. The process may overcome traditional power imbalance and encourage changes among both users and professionals that could enhance the dyadic relationship.

Coordinating Mental Health Services for People with Serious Mental Illness: A Scoping Review of Transitions from Psychiatric Hospital to Community

Effective coordination as people with serious mental illness (SMI) move between care settings is essential. We aimed to review challenges to care coordination for people with SMI and identify approaches for improving it. Sixteen articles were identified. Two main challenges emerged: people with SMI facing adjustment challenges during transitions and services struggling to provide continuity of care. Effective approaches addressed coordination challenges and resulted in better improvements in service utilization, social functioning and quality of life. Future interventions may benefit from shared decision-making, support for caregivers, and addressing the challenges associated with complicated medication regimes and accessing medications.

Perceptions of shared decision-making in severe mental illness: An integrative review

WHAT IS KNOWN ABOUT SHARED DECISION-MAKING?: There is increasing evidence of the positive impact of shared decision-making on health outcomes. There has been little exploration of shared decision-making regarding people diagnosed with serious mental illness from the perspectives of key stakeholders including consumers, families and mental health professionals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Consumers show variability in the preference for their involvement. Most stakeholders acknowledge the importance of family involvement. MHPs should share the responsibility and right to facilitate consumer involvement. There is bidirectional association between shared decision-making and therapeutic relationships. The practice of shared decision-making is related to multiple factors, and one main perceived barrier is time. The majority of studies are from Western countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making. Inter-professional collaboration should be integrated into shared decision-making. It might require lengthier consultation time. Studies in non-Western countries are needed to fully understand the impact of culture on shared decision-making. Abstract Introduction Shared decision-making (SDM) has been broadly advocated in health services and constitutes an important component of patient-centred care and relationship-based care. Aim To review available literature related to perceptions of key stakeholders about shared decision-making in serious mental illness. Method An integrative review was conducted through a search of four online databases from January 2012 to June 2019. Results Forty-six articles were included. Six themes were generated from the data analysis: (a) dynamic preferences for SDM, (b) various stakeholders are rarely involved, (c) SDM is not routinely implemented, (d) multiple facilitators and barriers to SDM, (e) SDM and therapeutic relationships interact, (f) SDM has a promising impact on health outcomes. Discussion Overall, most stakeholders have recognized the importance and flexibility of SDM in serious mental illness, although it is not routine in mental health service. Consumer preferences show variability in their involvement. Most stakeholders acknowledged the importance of family involvement to treatment decision-making. There are several significant challenges to practice SDM. It may require extended consultation times and increasing empirical evidence regarding the SDM outcomes, as well as integrating inter-professional collaboration into SDM. Most studies were conducted in Western culture. Implications for practice Mental health nurses should elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making when consumers prefer their families to be involved. Inter-professional collaboration should be integrated into shared decision-making. The practice of shared decision-making might need extended consultation time and more robust evidence about the outcome of shared decision-making. Studies in non-Western cultures are needed to fully understand cultural issues of shared decision-making.

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

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

Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care

Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n = 27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.

A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems

BACKGROUND

The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions.

METHODS

Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically.

RESULTS

Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management.

CONCLUSIONS

Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Early Psychosis Service User Views on Digital Technology: Qualitative Analysis

BACKGROUND

Digital technology has the potential to improve outcomes for people with psychosis. However, to date, research has largely ignored service user views on digital health interventions (DHIs).

OBJECTIVE

The objective of our study was to explore early psychosis service users' subjective views on DHIs.

METHODS

Framework analysis was undertaken with data obtained from 21 semistructured interviews with people registered with early intervention for psychosis services. Robust measures were used to develop a stable framework, including member checking, triangulation, independent verification of themes, and consensus meetings.

RESULTS

The following 4 themes were established a priori: acceptability of technology in psychosis and mental health; technology increasing access to and augmenting mental health support; barriers to adopting DHIs; and concerns about management of data protection, privacy, risk, and security of information. The following 2 themes were generated a posteriori: blending DHIs with face-to-face treatment and empowerment, control, and choice. DHIs were also viewed as potentially destigmatizing, overcoming barriers faced in traditional service settings, facilitating communication, and empowering service users to take active control of their health care.

CONCLUSIONS

In the first study of its kind, early psychosis service users' were largely positive about the potential use of DHIs supporting and managing mental health. Overall, service users felt that DHIs were a progressive, modern, and relevant platform for health care delivery. Concerns were expressed around privacy and data security and practical barriers inherent within DHIs, all of which require further attention. Future research should explore whether findings transfer to other service user groups, other technology delivery formats, and across a range of treatment modalities.

Finding Inspiration From the Philosophy of Maurice Merleau-Ponty for the Practice of Psychiatric-mental Health Nursing

The philosophy of Maurice Merleau-Ponty, a unique blend of existentialism and phenomenology, deserves to be better known in psychiatric-mental health nursing. This philosophy is particularly pertinent to the contemporary recovery movement that seeks to dispel the therapeutic nihilism regarding conditions such as schizophrenia, borderline personality, and substance use disorders. This paper provides an overview of Merleau-Ponty's life and work, with emphasis on selected elements of his philosophy that are inspirational for the clinical practice of psychiatric-mental health nursing.

Engagement-focused care during transitions from inpatient and emergency psychiatric facilities

OBJECTIVES

As many as 40% of those with serious mental illness (SMI) do not attend any outpatient visits in the 30 days following discharge. We examined engagement-focused care (EFC) versus treatment as usual in a university-based transitional care clinic (TCC) with a 90-day program serving individuals with SMI discharged from hospitals and emergency rooms. EFC included a unique group intake process (access group) designed to get individuals into care rapidly and a shared decision-making coach.

METHODS

Assessments of quality of life, symptomatology, and shared decision-making preferences were conducted at baseline, at 3 months corresponding to the end of TCC treatment and 6 months after TCC discharge. Communication among the patients and providers was assessed at each visit as was service utilization during and after TCC.

RESULTS

Subjective quality of life improved in EFC. Prescribers and patients saw communication more similarly as time went on. Ninety-one percent of patients wanted at least some say in decisions about their treatment.

CONCLUSIONS

SDM coaching and improved access improve quality of life. Most people want a say in treatment decisions.