Mental Settings Research Articles

Models of Consultation-Liaison Psychiatry: A Scoping Review

Abstract Consultation-liaison psychiatry (CLP) is a subspecialty of clinical psychiatry that includes clinical, teaching, and research activities of psychiatrists and allied mental health professionals in the nonpsychiatric divisions of a general hospital. The development of C-L psychiatry began slowly in the early 20th century (1900–1930s), when psychiatric treatment started moving from mental hospital setting to a general hospital setting. Since then, it has evolved significantly as a subspecialty, and, over the years, various models and approaches towards consultation and liaison with other departments have been proposed by different authors. In this scoping review, we attempt to understand the path of evolution of CLP, the various models that have been proposed over the years, and the available evidence for their efficacy and utility. Though many studies have been done regarding the various approaches towards CLP, much more robust, longitudinal research focussed on the impact of the various models of service and their interconnections need to be undertaken.

Abstinence Self-Efficacy and Resilience in Persons with Substance Use Disorder

Abstract Context: Substance use affects the personal, social, and familial aspects of a person’s life and is usually persistent, chronic, and relapsing in nature. Self-efficacy and resilience are important in the process of recovery of these persons. Aims: The current study aimed to examine the abstinence self-efficacy and resilience of persons with substance use disorder. Study Design: The study adopted a descriptive cross-sectional research design. Materials and Methods: Convenience sampling technique was used to select 60 patients in a tertiary mental health-care setting. The tools used were Connor–Davidson Resilience Scale and Alcohol Abstinence Self-Efficacy Scale. Results: The mean resilience was 76.52 ± 14.320 and the mean abstinence self-efficacy (confidence) was 57.50 ± 19.108. There was also a significant positive correlation between resilience and abstinence self-efficacy (confidence), r = 0.325, P = 0.011. Conclusions: The study findings indicate that patients with substance use disorder have moderate abstinence self-efficacy and resilience. Resilience and abstinence self-efficacy can be further enhanced in substance-using persons through proper interventions which will help to maintain long-term abstinence.

Supporting the Safe Use of the Dorsogluteal Intramuscular Injection Site: An Evidence-Based Quality Improvement Project.

Administering intramuscular (IM) injections is common in the adult mental health patient care setting, using the deltoid, vastus lateralis, ventrogluteal, or dorsogluteal site. Mental health nurses frequently use the dorsogluteal site to administer short and long-acting IM injections as specified in the drug package insert or because of patient agitation. However, the site is often not recommended due to the potential risk of nerve injury. Aims of this evidence-based quality improvement project were to (1) determine the best evidence for supporting the safe use of the dorsogluteal site for short and long-acting IM injections and (2) implement this evidence through nurse education. This project had two phases: Determining best evidence through an integrative literature review and implementing the recommendations to use the dorsogluteal site when directed by the drug package insert, clinical need, nursing judgment, or patient preference. Implementation followed the Plan-Do-Study-Act quality improvement process and involved written resources and simulation. Evidence supported the use of the dorsogluteal site in four instances and the importance of education. Nurses were highly satisfied with the education and opportunity to practice their skills with feedback during return demonstration. After studying nurses' follow-up survey results, a refresher simulation and medical center guideline were completed. There were no reports of IM injection patient injuries after 2 years and approximately 768 dorsogluteal and ventrogluteal IM injections in the academic medical center. Pursuing recent and possibly overlooked evidence provided guidance in supporting the safe use of the dorsogluteal site for IM injections.

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study

AimDevelop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions. BackgroundGuidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed. Methodology/approachA Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity. ResultsThe guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery. ConclusionThe guidance developed has face and content validity.

Indigenous mental healthcare and human rights abuses in Nigeria: The role of cultural syntonicity and stigmatization.

Indigenous mental healthcare using traditional non-western methods termed "unorthodox approaches" has been observed in Nigeria historically. This has been largely due to a cultural preference for spiritual or mystical rather than biomedical formulations of mental disorder. Yet, there have been recent concerns about human rights abuses within such treatment settings as well as their tendency to perpetuate stigmatization. The aim of this review was to examine the cultural framework for indigenous mental healthcare in Nigeria, the role of stigmatization in its utilization and interrogate the issues of human rights abuses within a public mental health context. This is a non-systematic narrative review of published literature on mental disorders, mental health service utilization, cultural issues, stigma, and indigenous mental healthcare. Media and advocacy reports related to human rights abuses in indigenous mental health treatment settings were also examined. International conventions on human rights and torture, national criminal legislation, constitutional provisions on fundamental rights and medical ethics guidelines relevant to patient care within the country were examined in order to highlight provisions regarding human rights abuses within the context of care. Indigenous mental healthcare in Nigeria is culturally syntonic, has a complex interaction with stigmatization and is associated with incidents of human rights abuses especially torture of different variants. Three systemic responses to indigenous mental healthcare in Nigeria include: orthodox dichotomization, interactive dimensionalization, and collaborative shared care. Conclusions: Indigenous mental healthcare is endemic in Nigeria. Orthodox dichotomization is unlikely to produce a meaningful care response. Interactive dimensionalization provides a realistic psychosocial explanation for the utilization of indigenous mental healthcare. Collaborative shared care involving measured collaboration between orthodox mental health practitioners and indigenous mental health systems offers an effective as well as cost-effective intervention strategy. It reduces harmful effects of indigenous mental healthcare including human rights abuses and offers patients a culturally appropriate response to their problems.

Nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings: An integrative review.

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.

‘Informed consent is a bit of a joke to me’: lived experiences of insight, coercion, and capabilities in mental health care settings

AbstractThe Independent Review of the Mental Health Act 1983 found that people’s experiences and self-knowledge were mislabelled as a ‘lack of insight’. Insight, a psychiatric concept, is defined as an ability to recognise one’s mental illness, awareness of one’s symptoms and compliance with treatment. Across different jurisdictions, legal scholars have raised concerns about the influence of insight on legal provisions for psychiatric care and mental capacity assessments, given its prevalent use in psychiatry and its absence from statutory criteria. However, outside of these findings, little is known about people’s lived experiences of ‘insight’ and the law. This article draws on narrative and photo-elicitation interviews with psychiatric survivors to argue that insight is an extra-legislative proxy for regulating involuntary detention and other coercion masked as consent. Finally, this article draws on the capabilities approach to deliver a justice argument for creating real opportunities to provide informed consent in mental health settings.

Brief admission—a promising novel crisis management method

Self-harm among children and adolescents is currently increasing and is strongly associated with suicide. 1 Griffin E McMahon E McNicholas F Corcoran P Perry IJ Arensman E Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007–2016. Soc Psychiatry Psychiatr Epidemiol. 2018; 53: 663-671 Crossref PubMed Scopus (81) Google Scholar Inpatient care in child and adolescent psychiatry has not yet evolved sufficiently to provide care that promotes the patient's autonomy and sense of self-determination, 2 Griffiths R Dawber A McDougall T Midgley S Baker J Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: systematic review and narrative synthesis. Int J Ment Health Nurs. 2022; 31: 35-50 Crossref PubMed Scopus (2) Google Scholar but there are various restrictive ways to handle impulsive self-harm and suicidal behaviours. 2 Griffiths R Dawber A McDougall T Midgley S Baker J Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: systematic review and narrative synthesis. Int J Ment Health Nurs. 2022; 31: 35-50 Crossref PubMed Scopus (2) Google Scholar Lengthy inpatient stays, coercive actions, and even forensic hospital admission have been used for life-saving purposes. 2 Griffiths R Dawber A McDougall T Midgley S Baker J Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: systematic review and narrative synthesis. Int J Ment Health Nurs. 2022; 31: 35-50 Crossref PubMed Scopus (2) Google Scholar Given the need for better approaches, it is crucial to study alternative ways to handle crises to prevent iatrogenic damage. 3 Cha CB Franz PJ Guzmán EM Glenn CR Kleiman EM Nock MK Annual research review: suicide among youth—epidemiology, (potential) etiology, and treatment. J Child Psychol Psychiatry. 2018; 59: 460-482 Crossref PubMed Scopus (258) Google Scholar Furthermore, coordinated treatment plans to prevent new crises by bridging the gap between inpatient and outpatient care are often obstructed by the different cultures of these care settings. To date, there are no standardised methods in child and adolescent inpatient care that ease or prevent self-harm without using coercive methods. New non-restrictive methods that reduce the need for lengthy constraining inpatient stays and promote continuity across inpatient and outpatient care are urgently required. 2 Griffiths R Dawber A McDougall T Midgley S Baker J Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: systematic review and narrative synthesis. Int J Ment Health Nurs. 2022; 31: 35-50 Crossref PubMed Scopus (2) Google Scholar Introducing brief admissions by self-referral in child and adolescent psychiatry: an observational cohort study in SwedenOur findings suggest that brief admissions can be successfully implemented in paediatric psychiatry and appear to be an effective crisis management method for adolescents, associated with reduced demand for emergency care. Future randomised controlled trials are warranted. Full-Text PDF

Bridge connection between depression and anxiety symptoms and lifestyles in Chinese residents from a network perspective.

Lifestyle habits are vital components of the culture of mental health treatment settings. We examined the bridge connection between depressive and anxiety symptoms and lifestyles from a network perspective using a population-based study. Face-to-face interviews were conducted with a provincially representative sample of 13,768 inhabitants from the Guangdong Sleep and Psychosomatic Health Survey based on standardized evaluation techniques. We identified the central symptoms by expected influence. The interconnection between depression and anxiety symptoms, as well as the bridge connectivity linking depression-anxiety symptoms and lifestyle factors, were assessed using the bridge centrality index. Network stability and sensibility analyses were performed using a case-dropping bootstrap procedure. The core symptom that exhibited the highest expected influence was fatigue or little energy, followed by uncontrollable worry, trouble relaxing, and sad mood in the depression-anxiety symptoms network, while guilt was the most interconnected symptom and had the highest bridge strength. Surrounding nodes of each node explained an average variance of 57.63%. Additionally, suicidal thoughts were recognized as collective bridging symptoms connecting lifestyle variables in the network integrating depression-anxiety symptoms with lifestyle factors. Current tobacco and alcohol consumption were positively associated with suicidal thoughts and irritability. Habitual diet rhythm and physical exercise frequency were linked to suicidal thoughts, guilt, and poor appetite or overeating. Suicidal thoughts, irritability, and guilt indicated the greatest connectivity with lifestyle factors. All networks had high stability and accuracy. These highlighted core and bridge symptoms could serve as latent targets for the prevention and intervention of comorbid depression and anxiety. It might be crucial for clinical practitioners to design effective and targeted treatment and prevention strategies aiming at specific lifestyles and behaviors.

Enabling QALY estimation in mental health trials and care settings: mapping from the PHQ-9 and GAD-7 to the ReQoL-UI or EQ-5D-5L using mixture models

PurposePatient-reported outcome measures (PROMs) are commonly collected in trials and some care settings, but preference-based PROMs required for economic evaluation are often missing. For these situations, mapping models are needed to predict preference-based (aka utility) scores. Our objective is to develop a series of mapping models to predict preference-based scores from two mental health PROMs: Patient Health Questionnaire-9 (PHQ-9; depression) and Generalised Anxiety Questionnaire-7 (GAD-7; anxiety). We focus on preference-based scores for the more physical-health-focussed EQ-5D (five-level England and US value set, and three-level UK cross-walk) and more mental-health-focussed Recovering Quality-of-Life Utility Index (ReQoL-UI).MethodsWe used trial data from the Improving Access to Psychological Therapies (IAPT) mental health services (now called NHS Talking Therapies), England, with a focus on people with depression and/or anxiety caseness. We estimated adjusted limited dependent variable or beta mixture models (ALDVMMs or Betamix, respectively) using GAD-7, PHQ-9, age, and sex as covariates. We followed ISPOR mapping guidance, including assessing model fit using statistical and graphical techniques.ResultsOver six data collection time-points between baseline and 12-months, 1340 observed values (N ≤ 353) were available for analysis. The best fitting ALDVMMs had 4-components with covariates of PHQ-9, GAD-7, sex, and age; age was not a probability variable for the final ReQoL-UI mapping model. Betamix had practical benefits over ALDVMMs only when mapping to the US value set.ConclusionOur mapping functions can predict EQ-5D-5L or ReQoL-UI related utility scores for QALY estimation as a function of variables routinely collected within mental health services or trials, such as the PHQ-9 and/or GAD-7.

Toward an optimized assessment of adolescent psychopathology risk: Multilevel environmental profiles and child irritability as predictors.

Adolescence is a developmental period during which youth experience vulnerability to psychopathology. To build the foundation for a parsimonious psychopathology risk calculator while capturing the complexity and dynamic nature of the environment, the current study aimed to identify distinct risk and resilience profiles with a wide range of environmental factors guided by Bronfenbrenner's biopsychosocial ecological system theory. The association between the early-mid childhood risk profiles and psychopathology in adolescence were examined. Moreover, the predictive utility of early childhood irritability was evaluated in addition to the risk profiles. The data from Future of Families and Child Wellbeing Study a nation-wide longitudinal study, were used in the latent profile analyses to identify the risk profiles with family, school, and neighborhood characteristics from 3 to 9years old. To capture the socio-environmental and cultural nuances, we extracted three subsamples, including Black/African American (n=2587), Hispanic/Latinx (n=1577), and White (n=776) for separate analyses. Risk profile memberships were used to predict adolescence psychopathology, including depression, anxiety, attention deficits, oppositional defiant disorder, and conduct disorder symptoms. The predictive utility of early childhood irritability above and beyond environmental risk profiles was evaluated using stepwise regression. Three risk profiles were identified in the Hispanic/Latinx and Black/African American subsamples, while four profiles were identified in White subsample. Almost all risk profile membership predicted both internalizing and externalizing psychopathology, while some profiles are predictive of externalizing symptoms only. Higher level of irritability predicted higher symptomatology in all five mental health outcomes above and beyond the environmental profiles. Distinct risk and resilience profiles primarily driven by parent and family characteristics were identified for all three major race/ethnicity groups. Our findings lay the foundation for a more efficient multi-tiered information gathering process in mental health clinical settings to aid the decision making for intervention and prevention.

The Impact of Smoking Regulations on the Daily Routine of Patients within an Irish Mental Health Setting

A high prevalence of smoking has been reported among people receiving care within inpatient and forensic mental health services. An Irish inpatient mental health service introduced a “smoke free campus” policy in 2018. Six semi-structured interviews were completed with patients within this setting in 2019. Using thematic analysis, five themes were identified: Experience of stakeholder support, routine, experience of being an inpatient, the meaning of smoking, and the experience and perception of the smoking policy and governing bodies. The findings have implications for staff who work in mental health inpatient settings or who develop policies regarding smoking on hospital sites.

Redefining the Role of Public Health Professionals Serving Black Youths Seeking Mental Health Care: Implications for Training and Mentoring.

Attrition rates for Black youths in mental health treatment settings are high, and the extant literature suggests this may be because treatment is not meeting their unique needs. Public health professionals, defined here as all individuals who work to increase the well-being of youths, can play a major role in changing these outcomes. The purpose of this article is to suggest a broader scope of practice, or a redefined role, for public health professionals who work with Black youths seeking outpatient mental health care and to explicate ways in which training and mentoring can help accomplish this goal. Bolstered by a socioecological conceptual model, we suggest 3 standards of practice that we believe must be satisfied to meet the requirement for this redefined public health professional role: using a sociocultural framework, exercising flexibility in one's assigned role, and understanding and incorporating culturally specific strengths and protective factors into care. (Am J Public Health. 2023;113(S2):S140-S148. https://doi.org/10.2105/AJPH.2022.307194).

Adherence to Clinical Guidelines for Dose Finding and Monitoring Methylphenidate Use: A Medical Record Audit in Child and Adolescent Mental Health Care and Pediatric Settings.

Background: Guideline adherence is important to ensure optimal and safe use of methylphenidate for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). We investigated adherence to Dutch guidelines regarding dosing and monitoring of methylphenidate in child and adolescent mental health care and pediatric treatment settings. Methods: Five hundred six medical records of children and adolescents were investigated in 2015 and 2016. We assessed adherence to the following guideline recommendations: (1) at least four visits during the dose-finding phase; (2) monitoring thereafter at least every 6 months; (3) measuring height and weight at least annually; and (4) the use of validated questionnaires to assess treatment response. Pearson's chi-squared test statistics were used to examine differences between settings. Results: Only a small portion of patients had at least four visits during the dose-finding phase (5.1% in the first 4 weeks to 12.4% in the first 6 weeks). Also, less than half of the patients (48.4%) were seen at least every 6 months. Height was recorded at least annually in 42.0% of patients, weight in 44.9%, and both recorded in a growth chart in 19.5%. Questionnaires to assess treatment response were only used in 2.3% of all visits. When comparing both settings, more patients in the pediatric settings were seen every 6 months, although height and weight were recorded more often in the mental health care setting. Conclusion: Overall, guideline adherence was low. Training of clinicians and adding guideline recommendations to electronic medical records templates may improve adherence. Additionally, we should aim to close the gap between guidelines and clinical practice by looking critically at the feasibility of guidelines.

Situational vulnerability within mental healthcare – a qualitative analysis of ethical challenges during the COVID-19 pandemic

BackgroundMental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability.MethodsWe present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability.ResultsDifficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics.ConclusionsApplying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability.

Improving diabetes care: findings from the first National Diabetes Inpatient Audit undertaken in a mental health setting

Background/Aims There has been no national audit of diabetes care provided in mental heath inpatient settings. This research was undertaken to reveal a snapshot of prevalence, services provided and the education delivered to both staff and patients, and in turn identify areas to improve care. Methods West London NHS Trust participated in the pilot mental health National Inpatient Diabetes Audit. A cross-sectional review of diabetes care on 11 wards informed the provision of a safe patient-centred high-quality diabetes service. Results The prevalence of diabetes was 23%. Almost all care was undertaken by non-specialist staff, none of whom received regular ward-based training for diabetes. A minority of staff knew how to access emergency diabetic services, and 75% of patients did not receive any structured diabetes education. Patient satisfaction scores were high. Staff requested more opportunities to access diabetes educational resources. Conclusions Diabetic care can be improved by modelling existing best practice from physical healthcare settings and by increasing diabetes education. Further data regarding evidence of safety, harms and quality is required to inform the development and commissioning of services to achieve the best diabetic care for this particularly vulnerable patient group.

Documenting language barriers in a general hospital psychiatry setting.

Previous research has demonstrated that without the use of professional interpreters, language barriers interfere with patient care. The literature recommends documenting the presence of language barriers in medical charts. To our knowledge, this mixed methods study is the first to examine language documentation practices in a Canadian inpatient psychiatry setting. The research team interviewed 122 patients admitted to a tertiary care psychiatry ward in Montreal, Canada between 2016-2017 to assess their ability to communicate in the healthcare establishment's languages (English/French). Nineteen participants identified as having a language barrier were selected for a qualitative analysis of the retrospective audit of their medical charts. The presence of a language barrier was reflected in 68% of these charts. When a language barrier was documented, professional interpreters were never used. Our qualitative analysis, informed by literature on medical discourse, aimed to provide clinical, administrative, and organizational recommendations to optimize the utilization of interpreting services in psychiatric wards. Documentation of language data was inconsistently collected, often vague, and shed light on the clinical challenges involved in differentiating language barriers from psychopathology. Normalization of limited care for language diverse patients was reflected in the clinical notes. Findings show that a change of organizational culture is imperative to provide optimal care to language diverse patients. We recommend clinician education and standardization of documentation practices, along with institutional policies supporting the systematic use of professional interpreters in mental healthcare settings, to maximize human rights and patient safety, and to bring medical practices to an acceptable standard of care.

Staff perceptions of patient inequalities in a UK secure mental healthcare setting

PurposeInequalities can have a cumulative effect that leads to the presentation and subsequent progression of mental health difficulties. The detrimental effects can be compounded in the healthcare environment if staff lack an awareness of patients’' inequalities, and therefore, educating staff is of particular importance. The development of awareness training requires a deep understanding of staff perceptions of patient inequalities in a secure mental health care setting and the impact that this can have on mental illness.Design/methodology/approachThe study was carried out using a qualitative design, where staff were asked to complete a 22-question survey from which the output is analysed using thematic analysis. In total, 100 patient-facing staff members working in a secure mental health facility completed the survey.FindingsThe results highlight that staff employed in a secure mental health care setting have an understanding of patient inequalities and how these can impact on patients in both the short and longer terms. The results highlighted the importance of awareness by staff and how an increase can have a significant benefit on the quality of the care provided within secure mental health facilities.Originality/valueThere is an increasing awareness of the impact of inequalities on mental health and how this can influence a patient’s journey. This study involving staff employed in a secure care mental health facility highlights the role of staff awareness of inequalities and also underlines the importance of understanding the key role of staff awareness in mental ill health.

A study protocol for the randomized controlled trial SAFIR FAMILY TALK: a selective primary preventive intervention vs. service as usual for children of parents with mental illness

BackgroundChildren of parents with mental illness have an increased risk of developing mental illness themselves throughout their lifespan. This is due to genetic factors but also environmental disadvantages during childhood associated with parental mental illness. Selective primary preventive interventions for the children are recommended to mitigate risk factors and strengthen protective factors, but large-scale, longitudinal studies are needed. This study aims to investigate the effect of the Family Talk Preventive Intervention in a cohort of children and their parents with mental illness.MethodsThe study is a randomized controlled trial with 286 planned families with at least one parent with any mental illness and at least one child aged 7 to 17 years. It will be carried out in the mental healthcare system in the Capital Region of Denmark. Families will be referred from hospitals and municipalities. The children and parents will be assessed at baseline and then randomized and allocated to either the Family Talk Preventive Intervention or service as usual. The intervention group will be assigned to Family Talk Preventive Intervention, a manualized programme consisting of ~ seven sessions for the family, including psychoeducation about parental mental illness and resilience in children, stimulating dialogue between family members and creating a common family narrative. The study period for both groups will be 12 months. Follow-up assessments will be conducted after 4 months and 12 months. The primary outcomes are the children’s level of functioning, parental sense of competence and family functioning.DiscussionGiven the prevalence of transgenerational transmission of mental illness, a systematic approach to prevention is needed in the mental healthcare setting. This study provides valuable knowledge on the Family Talk Preventive Intervention with a large sample size, inclusion of any parental mental illness and examination of the primary outcomes.Trial registrationClinicalTrials.gov NCT05615324. Registered on 26 October 2022. Retrospectively registered.

VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs.

United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.