A call for digital inclusion initiatives in mental health services: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Digital tools such as video calls or mobile phone applications (apps) are increasingly used in the provision of mental healthcare. There is evidence that people with mental health problems are more likely to face digital exclusion: that is, they do not have access to devices and/or skills to use technology. This leaves some people unable to use digital mental health services (e.g., apps or online appointments) or to benefit more generally from access to the digital world (e.g., online shopping or connecting with others virtually). People can be digitally included through initiatives that provide devices, Internet and digital mentoring to increase knowledge and confidence when using technology. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Some initiatives in academic studies and grey literature have been shown to increase access to and knowledge of technology, but this has been outside of mental health care settings. There are currently limited digital inclusion initiatives that take into consideration the specific needs of people with mental health problems, and how they can be equipped and familiarised with digital technologies to help their recovery journey and everyday life activities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further work is needed to improve the provision of digital tools in mental health care, with more practical digital inclusion initiatives to ensure equal access for all. If digital exclusion is not addressed, the gap between people with and those without digital skills or access to technology will continue to grow, enlarging mental health inequalities.

ABSTRACT

INTRODUCTION: The rise in the provision of digital healthcare during the pandemic has called attention to digital exclusion: inequality in access and/or capacity to use digital technologies. Digital exclusion is more profound in people with mental health problems, leaving an implementation gap of digital practice in mental health services.

AIM

Identify the available evidence of (a) addressing digital exclusion in mental health care and (b) the practical solutions to enhance uptake of digital mental health.

METHOD

Digital inclusion initiatives were searched from both academic and grey literature available and published between the years 2007 and 2021.

RESULTS

A limited number of academic studies and initiatives were found that supported people with mental health difficulties who had limited skills and/or access to overcome digital exclusion.

DISCUSSION

Further work is needed to combat digital exclusion and establish ways to reduce the implementation gap in mental health services.

IMPLICATIONS FOR PRACTICE

Access to devices, Internet connectivity and digital mentoring for mental health service users is essential. More studies and programmes are needed to disseminate impact and results for digital inclusion initiatives for people with mental health problems and to inform best practice for digital inclusion within mental health services.

mHealth technology to assess, monitor and treat daily functioning difficulties in people with severe mental illness: A systematic review

Severe mental illness (SMI) is associated with poor daily functioning; however available interventions currently under-deliver on their recovery prospect. Mobile digital health (mHealth) interventions are increasingly being developed and evaluated, and have the potential to support recovery. This review evaluates the use of mHealth technology to assess, monitor and reduce functioning difficulties in people with SMI. Studies were systematically searched on multiple databases. Study quality was assessed and double-rated independently. Findings were organised using a narrative synthesis and results were summarised according to the mHealth device purpose, i.e., assessment and monitoring or intervention. Thirty-eight studies comprised of 2262 participants met the inclusion criteria. Smartphones were the most popular mHealth device; personal digital assistants, wearables and tablets were also used. mHealth was widely found to be acceptable and feasible, with preliminary findings suggesting it can support functional recovery by augmenting an intervention, simplifying the assessment, increasing monitoring frequency and/or providing more detailed information. Considerations for overcoming barriers to implementation, recommendations for future research to establish effectiveness, personalisation and specification of mHealth devices and methodologies are discussed. The value of mHealth for remote delivery of recovery based interventions is also considered.

Is there an association between caregiver antipathy and psychosis? A systematic review

PURPOSE

Existing reviews of trauma and psychosis have identified associations between childhood emotional abuse (CEA) and psychosis. However, conceptual issues relating to assessment of CEA limit the conclusions that can be drawn from the literature. The aim of this review was to identify and evaluate studies reporting an association between childhood experiences of caregiver antipathy (i.e. criticism, hostility, coldness, or rejection from a parental figure experienced prior to age 17 years) and psychosis symptoms/diagnosis.

METHODS

Five databases were systematically searched for articles published until May 2020. Studies were evaluated against inclusion/exclusion criteria, and a narrative synthesis of findings was completed. Study quality was assessed by two independent raters.

RESULTS

Fourteen studies comprised of 1,848 participants met inclusion criteria. Twelve of these studies found significant associations between caregiver antipathy and psychosis, and two did not. There was evidence that adults with schizophrenia-spectrum diagnoses report more severe caregiver antipathy in childhood than non-clinical controls and that caregiver antipathy severity is positively correlated with psychosis symptom severity. Most studies received weak or moderate quality ratings and all used cross-sectional or case-control designs which showed associations, rather than causal relationships, between childhood caregiver antipathy and later psychosis.

CONCLUSIONS

Future research would benefit from more rigorous and valid assessment of CEA, use of multivariate methods to account for possible patterns of co-occurrence, and longitudinal study designs to make more robust causal claims. The findings may have important implications for the delivery of psychological care for people with psychosis who report adverse caregiving experiences.

PRACTITIONER POINTS

People with schizophrenia-spectrum diagnoses may report more severe caregiver antipathy in childhood than non-clinical controls. Caregiver antipathy severity appears to be positively correlated with psychosis symptom severity in clinical and non-clinical populations. Clinicians should consider the possible impact of caregiver antipathy on psychosis symptoms, their content and distress maintenance. Clinicians should also recognise the potential impact of adverse caregiving experiences on therapeutic relationships, patterns of help-seeking and service engagement. Best practice in clinical services would be to adopt individual, formulation-based approaches within trauma-informed models of care.

Thinking about other's mistakes: contrasting patterns of performance in groups high or low in autistic or psychopathic traits

Introduction: Counterfactual thinking refers to thoughts such as, "What if … ?" or "If only … " that hypothesise about how past events might have turned out differently. It is a functional process, allowing us to reflect upon and solve problems, and to evoke appropriate responses. It is thought to involve both cognitive and emotional processes, and is linked to the development of false belief and moral emotions. Methods: The present study compared responses to a novel task, "Counterfactual Judgments", in students who scored high or low on self-report measures of autistic or psychopathic traits, two conditions putatively associated with deficits in empathy. Results: Contrasting patterns of performance were revealed: those with high versus low autistic traits gave harsher ratings of blame for others' mistakes and showed reduced sensitivity to punitive counterfactual alternatives, whereas those with high versus low psychopathic traits gave lower ratings for moral judgments of regret and guilt. A self-report questionnaire measure of empathy also provided some evidence of reduced empathic processing in both the high trait groups. Conclusions: The findings are considered in the light of the possible contributions of cognitive versus emotional processes to counterfactual thinking. The possible implications for managing social dysfunction in clinical populations are also discussed.

Derailing the trolley: Everyday utilitarian judgments in groups high versus low in psychopathic traits or autistic traits

Moral decision-making has been linked with empathy. The present study built on previous work examining the relationship between psychopathy or autism spectrum disorder (ASD), two conditions putatively associated with deficits in empathy, and utilitarian decision-making. Students scoring high on self-report measures of psychopathic or autistic traits were presented with a novel task, 'Utilitarian Judgments', and compared to low trait control groups. This study replicated the classic finding that more direct links between the agents' actions and harm to victims mitigated utilitarian decision-making. It also found that participants made more utilitarian decisions when outcomes involved extreme physical versus everyday social harm. Enhanced utilitarian decision-making was not observed in those scoring high for either psychopathic or autistic traits, although both high trait groups reported that they would experience less discomfort than their low trait counterparts. Verbal reasoning differences were observed for the high autistic trait group, but not the high psychopathic trait group. The dilemmas that have been typically used to explore utilitarian decision-making describe extreme, hypothetical events involving physical or serious emotional harm. The present findings suggest that this might limit the generalisability of the existing literature and over-emphasise the tendency to make utilitarian decisions when considering everyday dilemmas.

The influence of subclinical psychopathic traits on responding to others' awkward requests

INTRODUCTION

Psychopathy is characterised by a postulated deficit in emotional empathy, with intact cognitive empathy. Although studies have examined performance on laboratory tasks within incarcerated populations, there is a paucity of work exploring how subclinical psychopathic traits translate into everyday social interactions.

METHODS

The present study investigated this by screening 502 university students with the Psychopathic Personality Inventory and comparing 20 high-scoring (10F; mean age = 19.85 years) and 19 low-scoring (15F; mean age = 21.00 years) participants on their responses to the Social Strategy Task. This comprises social scenarios that each end with an awkward request posed by the main character. Participants provided verbal responses and rated the awkwardness of each situation. Verbal responses were classified into positive or negative social strategies, denoting the extent of compliance with requests.

RESULTS

The groups were compared using analysis of variance and t-tests. The high psychopathic trait group used fewer positive social strategies than the low group was less polite in emotional tone and perceived situations as less awkward.

CONCLUSIONS

The findings are considered in relation to the postulated dissociation between intact cognitive empathy and impaired emotional empathy. The potential implications for clinical interventions are briefly discussed.

Going 'above and beyond': are those high in autistic traits less pro-social?

Few studies have explored how the cognitive differences associated with autistic spectrum disorder translate into everyday social behaviour. This study investigated pro-social behaviour in students scoring high and low on the autism-spectrum quotient (AQ), using a novel scenario task: ‘Above and Beyond’. Each scenario involved an opportunity to behave pro-socially, and thus required balancing the needs of a character against participants’ own interests. High AQ participants both generated responses and selected courses of action that were less pro-social than those of the low AQ group. For actions of low pro-social value they gave higher self-satisfaction ratings; conversely, they gave lower self-satisfaction ratings for high pro-social actions. The implications for everyday functioning are considered for those with high autistic traits.