Users Of Psychiatric Services Research Articles

It is Time for the CBT Songs: Music as a Medium to Deliver Cognitive Behaviour Therapy

The results of a national poll of listeners to a popular British music station in 2004 suggested that, the best way to ameliorate one's depressive symptoms musically is to listen to ‘I Know It's Over’ by Smiths. This is hardly surprising. We are all aware of the healing power of music. Music therapy groups are popular among staff and the users of psychiatric services, and are often funded by the public health services. In their Cochrane review to find out whether therapeutic use of music is effective in reducing the symptoms of depression, Maratos, et al. found only five studies that met their inclusion criteria. Due to the marked variations in interventions, the populations studied, and the outcome measures, it was not possible to conduct the metaanalysis. However, it was reported that four of these studies reported some improvement in depression among those who received music therapy.

Service users' experiences of participation in decision making in mental health services

Despite the potential positive impact of shared decision making on service users knowledge and experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. This study highlights the desire of users to participate more actively in decision making and demonstrates that persons with SMI struggle to be seen as competent and equal partners in decision-making situations. Those interviewed did not feel that their strengths, abilities and needs were being recognized, which resulted in a feeling of being omitted from involvement in decision-making situations. The service users describe some essential conditions that could work to promote participation in decision making. These included having personal support, having access to knowledge, being involved in a dialogue and clarity about responsibilities. Mental health nurses can play an essential role for developing and implementing shared decision making as a tool to promote recovery-oriented mental health services. Service user participation in decision making is considered an essential component of recovery-oriented mental health services. Despite the potential of shared decision making to impact service users knowledge and positively influence their experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. In order to develop concrete methods that facilitate shared decision making, there is a need for increased knowledge regarding the users' own perspective. The aim of this study was to explore users' experiences of participation in decisions in mental health services in Sweden, and the kinds of support that may promote participation. Constructivist Grounded Theory (CGT) was utilized to analyse group and individual interviews with 20 users with experience of serious mental illness. The core category that emerged in the analysis described a 'struggle to be perceived as a competent and equal person' while three related categories including being the underdog, being controlled and being omitted described the difficulties of participating in decisions. The data analysis resulted in a model that describes internal and external conditions that influence the promotion of participation in decision making. The findings offer new insights from a user perspective and these can be utilized to develop and investigate concrete methods in order to promote user's participation in decisions.

Cancer survival in the context of mental illness: a national cohort study

ObjectiveTo explore the reasons for worse cancer survival in people with experience of mental illness, including differences by cancer type and psychiatric diagnosis. MethodNew Zealand breast and colorectal cancer registrations (2006–2010) were linked to psychiatric hospitalization records for adults (18–64 years). Cancer-specific survival was compared for recent psychiatric service users and nonusers using Cox regression. The contributions of deprivation, comorbidity and stage at diagnosis were assessed for those with schizophrenia or bipolar affective disorder (Group A) and others using mental health services (Group B). ResultsOf 8762 and 4022 people with breast and colorectal cancer respectively, 440 (breast) and 190 (colorectal) had recent contact with psychiatric services. After adjusting for confounding, risk of death from breast cancer was increased for Group A [Hazard Ratio (HR) 2.55 (95% confidence interval 1.49–4.35)] and B [HR 1.62 (1.09–2.39)] and from colorectal cancer for Group A [HR 2.92 (1.75–4.87)]. Later stage at diagnosis contributed to survival differences for Group A, and comorbidity contributed for both groups. Fully adjusted HR estimates were breast: Group A 1.65 (0.96–2.84), B 1.41 (0.95–2.09); colorectal: Group A 1.89 (1.12–3.17), B 1.25 (0.89–1.75)]. ConclusionsThe high burden of physical disease and delayed cancer diagnosis in those with psychotic disorders contributes to worse cancer survival in New Zealand psychiatric service users.

Individual, social and contextual factors associated with psychiatric care outcomes among patients with intellectual disabilities in the emergency department.

Individuals with intellectual disabilities (ID) are disproportionately high users of psychiatric emergency services. Despite the demand for psychiatric assessments in the emergency department (ED), no clear guidelines have been established as to what factors should guide clinical decision-making processes. The current study aimed to explore individual, social and contextual factors related to psychiatric care outcomes among patients with ID in the emergency department. Emergency department charts were reviewed for 66 individuals with ID who visited the emergency department during a psychiatric crisis. Standardised crisis severity scores were significantly higher in patients seen by psychiatrists as compared with patients who did not receive psychiatric consultations in the emergency department. A significantly greater proportion of patients with moderate or severe levels of ID (vs. borderline/mild) received psychiatric consultations. Emergency department visits resulting in inpatient hospital admission did not differ from those that did not, with the exception of the level of ID: patients admitted to psychiatric inpatient care were more likely to have moderate or severe levels of ID. The psychiatric care experiences of patients with ID in the emergency department appear highly variable. Further research focused on emergency department clinical decision-making practices concerning this population is warranted.

What in-patients want: a qualitative study of what's important to mental health service users in their recovery (Wayfinder Partnership)

Purpose – The purpose of this paper is to present a qualitative analysis of the facilitators of recovery in in-patient psychiatric rehabilitation from the service users’ perspective. Design/methodology/approach – Interviews with 31 in-patients were coded and analysed thematically at an interpretive level using an inductive approach. Findings – The dominant themes identified were hope, agency, relationships and opportunity. Totally, 20 subthemes were identified. Agency was more important to men than women and agency, hope and relationships were all more important to detained patients. Research limitations/implications – Interview data were collected in writing rather than taped. The results may not be transferrable to patient populations with significantly different demographic or service factors. Practical implications – Services need to target interventions at the areas identified by service users as important in their recovery. The findings suggest both environmental and relational aspects of care that may optimise recovery. Services also need to be able to measure the quality of the care they provide. A brief, culturally valid and psychometrically assessed instrument for measuring the recovery orientation of services is required. Originality/value – As far as the authors are aware no qualitative work to date has examined the recovery experiences of psychiatric rehabilitation in-patient service users in order to understand what services require to do to enable recovery from their perspective. The conceptual framework identified in this paper can be used to develop a service user self-report measure of the recovery orientation of services.

Perceptions of psychosocial disability amongst psychiatric service users and caregivers in South Africa.

BackgroundIn many parts of South Africa there is little support for people with psychosocial disability caused by schizophrenia, beyond provision of psychotropic medications. Appropriate community-based psychosocial rehabilitation interventions are a crucial element of mental health service development.ObjectivesThis study aimed to use an explanatory model of illness framework to document experiences of illness, disability and recovery amongst service users with schizophrenia and their caregivers in a poorly resourced area in the North West Province. Data were used to provide recommendations for a contextually appropriate non-specialist facilitated group psychosocial rehabilitation intervention.MethodEighteen in-depth individual interviews were conducted: nine with schizophrenia service users and nine with caregivers. Interviews were conducted by two trained field researchers; both clinical psychologists fluent in the first language of participants. All interviews were recorded, translated and transcribed. Data were thematically analysed using NVivo 9.ResultsParticipants linked the illness to witchcraft, poverty and stress. Family conflict was recognised in the course of the illness, causing stress and challenges for emotional well-being. Knowledge of diagnosis and biomedical treatment was minimal. Key factors recognised by service users as promoting recovery were the ability to work, and the support of traditional healers and religious structures.ConclusionBased on the findings of this study, a group psychosocial rehabilitation intervention emerged as a recommendation, with the incorporation of psycho-education, adherence support, coping skills, and opportunities for income generation and productive activity. The importance of also enlisting the support of religious leaders and traditional healers in supporting recovery is emphasised.

The Therapeutic Relationship After Psychiatric Admission

The therapeutic relationship is one of the most central and important factors in the treatment of mental health disorders. A better therapeutic relationship is associated with service engagement, medication adherence, and satisfaction with services. This study aimed to compare the demographic and clinical factors associated with the therapeutic relationship in voluntarily and involuntarily admitted psychiatric service users. We found that individuals who had been admitted involuntarily, who had a diagnosis of a psychotic disorder, and who reported higher levels of perceived pressures on admission were more likely to have a poorer therapeutic relationship with their consultant psychiatrist. Greater levels of insight and treatment satisfaction, together with higher levels of procedural justice experienced on admission, were associated with a better therapeutic relationship. We found that the level of perceived coercion on admission was not related to the therapeutic relationship. Targeted interventions to improve the therapeutic relationship, particularly for involuntarily admitted service users, are discussed.

Estigma estructural, género e interseccionalidad. Implicaciones en la atención a la salud mental

El objetivo de este trabajo es describir las formas y manifestaciones más comunes del estigma estructural desde la perspectiva de un grupo de personas que acudieron a cuatro centros de atención por un diagnóstico psiquiátrico o neuropsiquiátrico (n=68), así como de un grupo de trabajadores del área de la salud que laboran en estos servicios en la Ciudad de México (n=95). Adoptamos un enfoque basado en la interseccionalidad que comprende el interjuego que existe entre los determinantes sociales, incluyendo el género, en los procesos de exclusión social en salud mental. En el estudio, de carácter cualitativo, se eligió la técnica de entrevista a profundidad, para lo cual se diseñaron guías específicas en proveedores y usuarios de servicios de atención psiquiátrica. Las entrevistas fueron registradas en audio, posteriormente transcritas y codificadas por medio de un programa especializado (Atlas ti, versión 7.0). Entre los hallazgos destaca el carácter estructural de la discriminación, la cual tiene repercusiones tanto para las personas afectadas por trastornos mentales graves como para el personal de salud. Por otra parte, en las narraciones de los entrevistados se evidencian ciertas barreras estructurales que inciden en la calidad de la atención, particularmente en el caso de aquellos usuarios que presentan múltiples condiciones de vulnerabilidad social que rebasan el alcance de los proveedores de servicios, constituyéndose en dilemas para éstos. Al final se analizan los principales desafíos para mejorar la calidad de la atención en el ámbito de la salud mental.

A survey of mental health professionals' knowledge, attitudes and preparedness to respond to domestic violence

BackgroundA high proportion of psychiatric service users experience domestic violence, yet most cases remain undetected by clinicians.AimsThis study aimed to assess mental health professionals' knowledge, attitudes and preparedness to respond to domestic violence.MethodInformation was collected on psychiatrists' and psychiatric nurses' knowledge, attitudes and preparedness towards the assessment of domestic violence, using an adapted Physician Readiness to Measure Intimate Partner Violence Survey.ResultsOne hundred and thirty-one professionals were surveyed. Only 20 (15%) professionals routinely asked all service users about domestic violence and just 36 (27%) provided information to service users following disclosure. Most professionals (60%) felt that they lacked adequate knowledge of support services, and 27% felt that their workplace did not have adequate referral resources for domestic violence. Nurses reported greater readiness to assess and manage domestic violence than psychiatrists (p < 0.001), despite psychiatrists reporting greater overall knowledge (p < 0.001).ConclusionsMental health professionals need to have clear referral pathways for service users who experience domestic violence, and to receive training on enhancing their knowledge and competencies to address domestic violence.

Violence in Acute Psychiatric Patients: A Cumulative Increased Risk with Polysubstance Abuse?

While comorbidity of serious mental illness (SMI) and substance abuse increases violence risk, less is known about additional effects of multiple substance abuse. By using a check list, data on substance abuse, violence, diagnoses, and Perceived Threat Control Override symptoms (TCO) were extracted from electronic patient files in 146 male patients who were extensive users of acute psychiatric services. Variables that were significant in univariate analysis were entered into a stepwise multivariate regression analysis. Odds ratios for violence increased from 5.3 in patients who abused one substance to 153.4 with the abuse of four or five substances (Step 1). The effect was moderated in Step 2 by having a diagnosis of mood disorder (OR = .17). In Step 3, only a trend indicated that one TCO component, “others control my thoughts and feelings,” increased the risk of violence (OR = 3.7). The positive effect sizes for polysubstance abuse were about two times larger in Step 3 than in Step 1. The findings indicate that including the number of abused substances may improve violence risk assessment in patients with SMI.

Linking abuse and recovery through advocacy: an observational study.

Aims. High numbers of psychiatric service users experience domestic violence, yet limited interventions exist for these victims. We piloted a domestic violence intervention for community mental health services to explore the feasibility of a future cluster randomized controlled trial. Methods. Quasi-experimental controlled design within five Community Mental Health Teams (three intervention and two control teams). The intervention comprised domestic violence training for clinicians' and referral to domestic violence advocacy for service users. Clinicians' (n=29) domestic violence knowledge, attitudes and behaviours were assessed before and 6 months post-training. Service users' (n=34) safety behaviours, unmet needs, quality of life and frequency/severity of abuse were examined at baseline and 3 months follow-up. Process evaluation data were also collected. Results. Clinicians receiving the intervention reported significant improvements in domestic violence knowledge, attitudes and behaviours at follow-up (p<0.05). Service users receiving the intervention reported significant reductions in violence (p<0.001) and unmet needs at follow-up (p<0.05). Conclusions. Interventions comprising domestic violence training for clinicians and referral to domestic violence advocacy may improve responses of psychiatric services. Low rates of identification among teams not receiving training suggest that future trials using service user outcomes are unlikely to be feasible. Therefore, other methods of evaluation are needed.

Discrimination in relation to parenthood reported by community psychiatric service users in the UK: a framework analysis

BackgroundExperienced discrimination refers to an individual’s perception that they have been treated unfairly due to an attribute and is an important recent focus within stigma research. A significant proportion of mental health service users report experiencing mental illness-based discrimination in relation to parenthood. Existing studies in this area have not gone beyond prevalence, therefore little is known about the nature of experienced discrimination in relation to parenthood, and how is it constituted. This study aims to generate a typology of community psychiatric service users’ reports of mental illness-based discrimination in relation to becoming or being a parent. A secondary aim is to assess the prevalence of these types of experienced discrimination.MethodsIn a telephone survey 2026 community psychiatric service users in ten UK Mental Health service provider organisations (Trusts) were asked about discrimination experienced in the previous 12 months using the Discrimination and Stigma Scale (DISC). The sample were asked if, due to their mental health problem, they had been treated unfairly in starting a family, or in their role as a parent, and gave examples of this. Prevalence is reported and the examples of experienced discrimination in relation to parenthood were analysed using the framework method of qualitative analysis.ResultsThree hundred and four participants (73% female) reported experienced discrimination, with prevalences of 22.5% and 28.3% for starting a family and for the parenting role respectively. Participants gave 89 examples of discrimination about starting a family and 228 about parenting, and these occurred in social and professional contexts. Ten themes were identified. These related to being seen as an unfit parent; people not being understanding; being stopped from having children; not being allowed to see their children; not getting the support needed; children being affected; children avoiding their parents; children’s difficulties being blamed on the parent’s mental health problem; not being listened to; and being undermined as a parent.ConclusionsThis research highlights the need for: greater support for parents with mental illness, those wishing to have children, and those who lose access or custody; services to better meet the needs of children with a mentally ill parent; training about discrimination for professionals; and parenting issues to be included in anti-stigma programmes.

Laughing at lunacy: othering and comic ambiguity in popular humour about mental distress

Jokes and humour about mental distress are said by anti-stigma campaigners to be no laughing matter. The article takes issue with this viewpoint, arguing that this is clearly not the case since popular culture past and present has laughed at the antics of those perceived as “mad”. Drawing on past and present examples of the othering of insanity in jokes and humour, the article incorporates a historical perspective on continuity and change in humour about madness/mental distress, which enables us to recognize that psychiatry is a funny-peculiar enterprise and its therapeutic practices in past times are deserving of funny ha-ha mockery and mirth in the present. By doing so, the article also argues that humour and mental distress illuminate how psychiatric definitions and popular representations conflict and that some psychiatric service users employ comic ambiguity to reflexively puncture their public image as “nuts”.

Improving services for people with personality disorders: Views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community.

829 – Domestic violence and mental disorders

Background There is little known about the extent to which men and women with mental disorders are at increased risk of being a victim of domestic violence. We therefore aimed to estimate the prevalence and risk of domestic violence victimisation among men and women with depressive and anxiety disorders, post-traumatic stress disorder, eating disorders, psychotic disorders, and among psychiatric service users. Methods We searched 18 biomedical and social sciences databases (including MEDLINE, EMBASE and PsycINFO) and supplemented the search by hand searching of key journals and reference lists of included articles, citation tracking, expert recommendations, and updating a systematic review on victimisation among people with mental disorders. We included cross sectional, cohort and experimental studies that reported on the prevalence and/or risk of adulthood domestic violence victimisation among people meeting either ICD or DSM diagnostic criteria for a mental disorder. Two reviewers independently extracted data and appraised study quality. Random effects meta-analysis was used to pool data where possible. Findings High quality papers reported a median prevalence of adult lifetime domestic violence in mental health service users of 30% (IQR 26% - 39%) in female inpatients and 33% (IQR 31%-53%) in female outpatients. There was an increased risk of experiencing domestic violence in all diagnostic groups and in men and women but there were few high quality studies for men. Interpretation Mental disorder is associated with a high prevalence and increased risk of being a victim of domestic violence in both men and women.

2932 – Natural social network project: one for all and all for one

Most users of psychiatric services shows jointly clinical severity, disability and marginalization so complex that it can not be answered fully only within the same services. Within the Mental Health Department of Lecce, in the Mental Health Center of Casarano it is started the Natural Social Network Project “One for all and all for one” aimed to provide a more adequate response to the needs of these patients. It will be identified patients with most psychosocial problems according to frequency of hospitalizations, emergency visits and rating scales (Brief Psychiatric Rating Scale, Life Skills Profile and Short Form 36 Health Survey). Then it will be identified with the patient a “facilitator”, or a person outside the CSM and longer fit into the everyday life of the patient (eg, relatives, friends, etc..). After that, the various parties involved (doctor, nurse, facilitator and user) agree an individual program based on which we make a psychoeducational path. The process will be checked quarterly with the presence of all the parties involved and monitored monthly or on the basis of needs. After one trial year it is expected a substantial improvement by the patient in the satisfaction of his needs and more generally in his rehabilitation.

Predictors of outcomes for users of mental health rehabilitation services: a 5-year retrospective cohort study in inner London, UK

There have been few recent studies reporting on the outcomes for users of psychiatric rehabilitation services. This group has complex, longer-term mental health problems. We aimed to investigate 5-year outcomes for this group and identify factors associated with outcome. Clinical outcome data on 141 users of a mental health rehabilitation service in inner London, UK, surveyed in 2005, were collected retrospectively 5years later. Positive outcome was defined for those who were inpatients in 2005 as achieving and sustaining community discharge, and for those who were community patients, as progressing to and sustaining a less supported community placement. Negative outcome was defined as remaining in the same placement, moving to more supported placement or having a psychiatric admission. Over 5years, 17 (12%) people died, 50 (40%) had a positive outcome, 33 (27%) remained in a placement with a similar level of support and 41 (38%) moved to a more supported placement and/or had a psychiatric admission. Thirteen (10%) people moved to independent accommodation and sustained their tenancy successfully. Those with a record of non-adherence with medication during the 5years were more likely to have a negative outcome (OR 8.60, 95% CI 3.41 to 21.70). Adherence to medication is an important factor in facilitating successful community discharge for people with complex mental health problems who require psychiatric rehabilitation.

Mental disorders diagnosed in childhood and at‐risk mental state in a help‐seeking population

Disorders usually first diagnosed in infancy, childhood or adolescence (DUFD-ICA) may have preceded the onset of psychosis by several years and share some co-morbidity with psychotic disorders, but only a few studies have investigated this aspect. We looked for past or current DUFD-ICA in a sample of first adult psychiatric service users assessed for the presence of an at-risk mental state with the Structured Interview for Psychosis-risk Syndromes (SIPS). We interviewed with the SIPS 159 first-time help seekers (age range 13-30 years) at adult psychiatric services who volunteered to participate in the study. For psychiatric diagnoses, we used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition-Text Revision. We also assessed retrospectively the presence of DUFD-ICA and administered the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment of Functioning. The sample has been subdivided diagnostically into first-episode psychosis, multiple episode psychosis, ultra-high risk (UHR) and other diagnoses. The risk for having one of first-episode psychosis, multiple episode psychosis or UHR was over 3.45 higher in the DUFD-ICA-positive history group than in the non-DUFD-ICA. Grouping the UHR with the not full-blown psychosis cases resulted in a further increase of the risk to 4.71. DUFD-ICA-positive participants scored higher than non-DUFD-ICA on the Positive, Negative and Disorganization scales of the SIPS and on several core-psychotic BPRS items. A positive history of DUFD-ICA increases the risk of a diagnosis of prodromal or current psychosis at help seeking. Impaired neurodevelopment may be shared among the psychoses and DUFD-ICA.

What has been learned from joint working between mental health professionals, patients and users of psychiatric services, their families and friends?

To outline what is known about collaborative work between the main stakeholders in mental health and psychiatry (professionals, patients or service users and family members). To learn from recent practice what are the main areas of joint work, what is working well, what are the key issues and problems and what has been learned from doing it. Service users and family members are valued in education and training. Service users as peer support workers have helped patients recover, and methods of participatory research can bring new insights. There is a need to support and build an evidence base for these new ways of working. The run-down of institutions, the new paradigm of recovery and human rights laws have led to increased joint working in the field of law and policy, research, education and training, service provision and coercion. Joint working challenges the old ways of knowledge creation and practices such as coercive treatment. More work is needed to build on what is being learned and move to genuine equality and partnership.

Psychiatric Nurses Explanations of Self-Harming Behaviour in Secure Forensic Settings: A Multi-Method Phenomenological Investigation

Aim: This paper reports on a study that explores psychiatric nurses` explanations of self-harming behaviors in secure forensic psychiatric environments. Background: There is evidence suggesting that there is a differential perception between psychiatric nurses and service users of the reasons for self-harming behaviors in secure settings. This gulf in perception, which may negatively impact on the care offered to service users, is a function of nurses’ lack of or limited knowledge of self-harm. Yet, research concerning nurses’ reasons for service users’ self-harming behaviors is limited. Methods: The study utilized a phenomenological methodology with semi-structured individual interviews (n=25) and focus group interviews (n=6x6). The data were analyzed thematically using Interpretative Phenomenological Analysis. Results: The findings indicate that the behavior of self-harm does not have fixed causes rather it has multiple causes which, in the main, relate to affect regulation, limited coping skills, rigid institutional regime and practitioners` negative attitudes. Conclusions: These findings have implications for practice and recommendations are made to improve this. Regular training and support should be provided for psychiatric nurses in secure environments in order to broaden their understanding of self-harm and its underlying motives. Improved understanding of self-harm may result in improved nurse-service user relationships and thus, safer and effective care provision.