Involvement of informal carers in discharge planning and transition between hospital and community mental health care: A systematic review.

WHAT IS KNOWN ON THE SUBJECT: Family members and friends (informal carers) are very important for providing support to people with mental health difficulties. When these carers are included to care planning patients seem to benefit, as they are less likely to relapse. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: There are three types of interventions including carers in the patients'transition 1) programmes that offer education in hospital; 2) programmes that involve carers in planning the patients discharge; and 3) programmes that involve carers in hospital care, discharge planning and also follow-up in the community. Interventions including carers that take place both in the hospital and the community have the clearest evidence for benefit on relapse reduction. WHAT ARE THE IMPLICATIONS FOR PRACTICE: Comprehensive interventions have the best evidence for effectiveness but challenges in their implementation and resourcing should be considered. It might worth trying to identify and test simpler interventions focusing on discharge planning that can be used in busy services and require more limited resources whilst providing opportunities for the participation of carers. ABSTRACT: INTRODUCTION: Involving informal carers (family and friends of patients) in mental health interventions can lead to positive clinical and psychosocial outcomes such as relapse prevention or treatment adherence. AIM/QUESTION: To explore the evidence on the effectiveness of different models that involve carers in the transition between hospital and community mental health care. METHODS: Five electronic databases (PsycINFO, CINAHL, MEDLINE, Embase and Scopus) and Grey literature (Open Grey and Grey Literature report) were systematically searched. The results were analysed using a narrative synthesis. RESULTS: Fourteen papers were identified. They described twelve interventions that were categorized into three groups: 1) purely educational programmes in preparation of discharge; 2) programmes that involved carers in planning the transition from the mental health inpatient treatment to community mental health services; and 3) programmes that bridged into the aftercare involving carers in community follow-up. The most comprehensive interventions, i.e. those including psychoeducation, care planning and aftercare follow-up were better evaluated and showed a clearer benefit in improving long-term outcomes and, in particular, reduce re-hospitalization. IMPLICATIONS FOR PRACTICE: Comprehensive interventions showed the clearest benefit in improving long-term clinical outcomes of patients. Future research should explore implementation, costs and cost-effectiveness, as comprehensive interventions delivered across different settings are likely to require wide-ranging organizational changes and significant resources.

Defining what a 'carer' is and the role they play in in-patient mental healthcare: A focus group study with patients, carers and clinicians.

BACKGROUND: The value of carer involvement has been extensively researched and promoted. However, the field lacks exploration of conceptual issues, which might help to explain why there are widespread difficulties in putting policy into practice in this area, as implementation rates remain low internationally. AIMS: This qualitative study explored patients', carers' and clinicians' perspectives on the role of carers in mental healthcare, particularly with regards to in-patient settings. METHOD: Sixteen focus groups were conducted with patients, carers and clinicians who have current or previous experience of in-patient settings. A thematic analysis was conducted on the transcripts, exploring two key domains: (a) what a 'carer' is, and (b) how the 'carer' role is described within the context of the hospital environment. RESULTS: Participants diverged in their opinions of what the 'carer' role entails, and the perceived helpfulness of it. Issues unique to the in-patient setting were identified, such as the role of the hospital environment in enabling or being a barrier to carer involvement. These differing perspectives and contextual factors had an impact on the position of carers in the hospital setting, as they could be viewed as helpful, a hindrance or as passive visitors, depending on the perspectives of clinicians. CONCLUSIONS: More clarity and agreement is needed between patients, carers and clinicians in terms of how the 'carer' role is defined. This has the potential to improve carers' experience of involvement in hospital settings.

"It's a matter of building bridges " - feasibility of a carer involvement intervention for inpatients with severe mental illness.

BACKGROUND: Family and friends (carer) involvement in the treatment of people with mental illness is widely recommended. However, the implementation remains poor, especially during hospital treatment, where carers report being excluded from care decisions. METHODS: We developed structured clinical procedures to maximise carer involvement in inpatient treatment. The aim of this study was to test their feasibility across four inpatient wards in East London and explore experiences of the participants. The intervention was delivered by clinicians (social therapists, nurses and psychiatrists) who were trained by the research team. Thirty patients and thirty carers received the intervention and completed research assessments and qualitative interviews after the intervention. 80% of the patients were followed up after six weeks of admission to complete quantitative questionnaires. Six clinicians were interviewed to explore their views on the intervention. Thematic analysis was used to analyse qualitative data. RESULTS: The intervention was found to be feasible to be delivered within the first week of admission in more than a half of the patients (53%) who provided consent. The main reasons why the interventions was not delivered in the remaining 47% of patients included staff or carers not being available, withdrawal of consent from the patient or patient being discharged prior to the intervention. Two themes were identified through thematic analysis. The first captured participant experiences of the intervention as facilitating a three-way collaborative approach to treatment. The second covered how patients' mental states and practicalities of inpatient care acted as barriers and facilitators to the intervention being implemented. CONCLUSIONS: Carer involvement in hospital treatment for mental illness is more difficult to implement than is commonly thought. This study has shown that a simple structured approach can facilitate a trialogue and that patients, clinicians and carers appreciate this approach to care. Our intervention provides clear and simple manualised clinical procedures that clinicians can follow. However, even the implementation of such procedures may be challenging in the absence of wider organisational support. The involvement of senior managers and clinical leaders might play a key role in overcoming barriers and support front-line clinicians to prioritise and implement carer involvement.

Psychosis or spiritual emergency? A Foucauldian discourse analysis of case reports of extreme mental states in the context of meditation.

Meditation is becoming increasingly popular in the West and research on its effects is growing. While studies point to various benefits of meditation on mental and physical health, reports of extreme mental states in the context of meditation have also been published. This study employed Foucauldian discourse analysis to examine how the experience of extreme mental states has been constructed in case reports and what kind of practices were employed to address them. The study analyses how extreme mental states associated with meditation are framed within the scientific literature and how such differential framings may affect the meaning making and help-seeking of persons experiencing these states. A systematic scientific literature search identified 22 case studies of extreme mental states experienced by practitioners of various types of meditation. The analysis suggests a discursive divide between two dominant framings: a biomedical discourse which constructs such experiences as psychiatric symptoms and an alternative discursive, which understands them as spiritual emergencies. Both approaches offered distinct therapeutic avenues. This divide maps onto the disciplinary divides within the mental health field more generally, which may obscure a better understanding of these experiences. However, the two discourses are not necessarily mutually exclusive and authors of three articles chose to blend them for their case reports. A supportive environment could help those experiencing extreme state integrate them into their lives. Our findings encourage collaboration between clinicians, therapists and spiritual teachers in order to make a range of approaches available.

Internet Use for Social Interaction by People with Psychosis: A Systematic Review.

People with psychosis (PWP) have difficulties in establishing and maintaining social connections. An earlier systematic review on the use of online social networking (OSN) in psychosis found only 11 studies published before January 2014, but with promising findings. These studies showed no difference in OSN use between PWP and general population. Given the limited number of articles found and the rapid advances in OSN, we carried out an update review to assess evidence on how PWP use OSN. Several electronic databases were searched for the literature published between January 2014 and May 2018. Data from included studies were narratively synthesized. Thirteen additional studies examined the use of OSN in PWP in 2014-2018. Updated evidence confirms that PWP seem to use OSN at least as much as the general population, although only when not acutely unwell. PWP who are younger and have higher education level are more likely to use OSN. There was no evidence of worsening psychological symptoms due to OSN. Some studies showed patient-reported concerns about negative experiences and the inability to identify online social contacts. The use of OSN by PWP is a subject of increasing interest with a rapidly developing evidence base. The frequent use of OSN by PWP and the absence of evidence of symptom worsening are encouraging findings. This would justify the inclusion of OSN among the strategies to reduce social isolation in psychosis. Research methodologies should be improved by developing standardized measures to assess use and associated risks.

What might affect acceptability of online positive psychology interventions for depression: a qualitative study on patient expectations'.

BACKGROUND: Positive psychology interventions are brief self-adminstered exercises designed to promote positive emotions, behaviours, or thoughts. They are potentially effective for reducing depression and are considered suitable for online dissemination to people with depression and related conditions, as they are assumed to be more acceptable than traditional symptom-focused approaches. However, there is little investigation into perceived acceptability and potential factors that might affect it. This might limit the development and evaluation of effective interventions. METHODS: Semi-structured interviews with patients with depression and/or anxiety (n = 18) and professionals, including GPs and psychologists (n = 5) were conducted on their perceptions of a proposed online intervention using positive psychology. Thematic analysis, according to Braun and Clarke, was used to identify meaningful patterns in the data. RESULTS: Four key themes were identified. The fit between the positive psychological approach and the patient's context, including their personality, symptoms and other treatments, was important in determining acceptability. Social aspects of interventions were thought to facilitate acceptability, as long as these were balanced. Support was identified as important in facilitating intervention suitability, although it was not without limitations. Finally, participants identified how design features can enhance acceptability. CONCLUSIONS: The findings suggest that positive psychology interventions might not be acceptable to all and that specific exercises might be more or less appropriate to deliver online. Design aspects can help to facilitate acceptability, beyond the psychological content. These findings may inform the design of future online psychology interventions for people with depression and anxiety, which can then be evaluated in future research.

How to make carer involvement in mental health inpatient units happen: a focus group study with patients, carers and clinicians.

BACKGROUND: Carers are family members or friends who support people with a mental health problem without being paid. Carer involvement in mental health treatment has been consistently supported by research evidence and promoted by policies but its implementation rates are poor. Particularly when patients are treated in inpatient units, carers often report being left without information or being excluded from decisions about treatment. In this study we have explored, along with staff perspectives, views of patients and carers who had a recent experience of inpatient mental health care on how to improve the implementation of carer involvement in inpatient care. METHODS: Sixteen focus groups were held with carers, patients and clinicians in London, United Kingdom. We included staff working in inpatient units and patients and carers who had experience of inpatient care in the last five years. Data from focus groups were analysed using thematic analysis. RESULTS: Eighty six participants in total (31 service users, 22 carers and 33 clinicians) attended the focus groups. Participants identified that generally, carer involvement should happen as soon as possible after admission, although this may be challenging in some cases. Carer involvement should include receiving information, participating in decisions about care and discharge and receiving emotional support by staff. When carers are involved, their personal knowledge of the patient's condition should be utilised. Challenges to carer involvement may include problems with identifying carers during a mental health crisis, obtaining valid patient consent, sharing appropriate information, and contacting and engaging carers. Additionally, it was perceived that all the ward staff need to be actively engaged in order to make carer involvement happen and this cannot be left only to specifically trained clinicians. CONCLUSIONS: These findings identify basic components that all family interventions in inpatient units should have. Further studies are needed to explore how and if purposively designed clinical interventions can improve carer involvement in inpatient treatment and, consequently, patient outcomes.

Psychosis seminars: an open forum for service users, carers and professionals.

BACKGROUND: Psychosis seminars enable service users, their carers and mental health professionals to meet outside of a formal care setting, increase understanding of mental illness and help establish a dialogue. AIMS: To explore feasibility of psychosis seminars in the UK and the experiences of participants. METHOD: Seven meetings attended by 25 people were held over a 3-month period. An open-ended questionnaire was returned by ten participants. Responses were subjected to content analysis. RESULTS: Benefits experienced were having an open forum for talking freely about mental health issues in a neutral space, learning from others about psychosis and hearing different views. Suggested adjustments were clarifying expectations of participants at the beginning, strengthening facilitation and increasing attendance. CONCLUSIONS: Psychosis seminars may help to establish a dialogue among users, carers and professionals and seem feasible in the UK, although adjustment to delivery can help their implementation. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) license.