Protocol for a randomised controlled trial of ketamine versus ketamine and behavioural activation therapy for adults with treatment-resistant depression in the community.

INTRODUCTION: Although short-term benefits follow parenteral ketamine for treatment-resistant major depressive disorder (TR-MDD), there are challenges that prevent routine use of ketamine by clinicians. These include acute dissociative effects of parenteral ketamine, high relapse rates following ketamine dosing and the uncertain role of psychotherapy. This randomised controlled trial (RCT) seeks to establish the feasibility of evaluating repeated oral doses of ketamine and behavioural activation therapy (BAT), compared with ketamine treatment alone, for TR-MDD. We also aim to compare relapse rates between treatment arms to determine the effect size of adding BAT to oral ketamine. METHODS AND ANALYSIS: This is a prospectively registered, two-centre, single-blind RCT. We aim to recruit 60 participants with TR-MDD aged between 18 and 65 years. Participants will be randomised to 8 weeks of oral ketamine and BAT, or 8 weeks of oral ketamine alone. Feasibility will be assessed by tracking attendance for ketamine and BAT, acceptability of treatment measures and retention to the study follow-up protocol. The primary efficacy outcome measure is the Montgomery-Asberg Depression Rating Scale (MADRS) measured weekly during treatment and fortnightly during 12 weeks of follow-up. Other outcome measures will assess the tolerability of ketamine and BAT, cognition and activity (using actigraphy). Participants will be categorised as non-responders, responders, remitters and relapsed during follow-up. MADRS scores will be analysed using a linear mixed model. For a definitive follow-up RCT study to be recommended, the recruitment expectations will be met and efficacy outcomes consistent with a >20% reduction in relapse rates favouring the BAT and ketamine arm will be achieved. ETHICS AND DISSEMINATION: Ethics approval was granted by the New Zealand Central Health and Disability Ethics Committee (reference: 2023 FULL18176). Study findings will be reported to participants, stakeholder groups, conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER: UTN: U1111-1294-9310, ACTRN12623000817640p.

'E koekoe te Tui, e ketekete te Kaka, e kuku te Kereru, The Tui chatters, the Kaka cackles, and the Kereru coos': Insights into explanatory factors, treatment experiences and recovery for Maori with eating disorders - A qualitative study.

BACKGROUND: Eating disorders are as common in Maori, the Indigenous people of Aotearoa-New Zealand, as they are in non-Maori; however, research has focused on the experiences of non-Maori. This paper will describe explanatory factors, treatment experiences and what helps with recovery for Maori. METHODS: Kaupapa Maori research methodology informed the methods and analysis. Fifteen semi-structured interviews comprised thirteen Maori participants with eating disorders (anorexia nervosa, bulimia nervosa and binge eating disorder) and two whanau (support network) members. A thematic analysis was undertaken by a first cycle of coding that used deductive structural coding to identify data describing participants' perceived causes of eating disorders, their experience of treatment and recovery. A second cycle of coding used inductive analysis with descriptive and pattern coding. RESULTS: Three overarching themes were antecedents (cumulative exposure), treatment (a system of complexities) and recovery (resource empowerment). Antecedents comprised cumulative exposure to body and sporting ideals and adversity as causal factors of eating disorders. In the treatment theme, a system of complexities critiqued rural settings for generalised mental health services, allocation of Maori cultural support, the economic burden of treatment, culturally incongruent treatment (methods, values) and a weight-focused discharge criterion. Recovery (resource empowerment) found appropriate health information, self-determination and connection to Maori culture and whanau aspirations helped with recovery. CONCLUSION: The diversity of birdcalls reminds us of the individuality of eating disorders. Health practitioners are reminded that just as the Tui, Kaka and Kereru possess their own unique birdcalls, so do Maori with eating disorders and their whanau have their own experiences, needs and required treatment responses.

Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences.

BACKGROUND: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role. AIM: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes. METHODS: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Maori youth with early psychosis, 10 family members and 4 Maori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. RESULTS: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce. CONCLUSION: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Psilocybin-assisted psychotherapy for treatment-resistant depression: Which psychotherapy?

This perspective paper explores the choice of psychotherapy for psilocybin-assisted psychotherapy for treatment-resistant depression. There is evidence to support the use of some psychotherapies in treating 'treatment-resistant' depression, and emerging evidence for the efficacy of psilocybin. The next step which is the focus of this paper is to identify psychotherapies that are both effective and congruent with the psilocybin experience. The evidence for the efficacy of the psychotherapies is drawn from a Cochrane review and the analysis of their congruence with the psilocybin experience is drawn from a qualitative meta-synthesis of the experience of psilocybin. The paper will examine whether three one-to-one psychotherapies identified as effective in the treatment of treatment-resistant depression are compatible with the psilocybin experience. Each psychotherapy will be examined in relation to its congruence with the qualitative evidence that suggests the choice of psychotherapy needs to give priority to the subjective experience, facilitate emotional processing, support connectedness with others, acceptance of the self as emotional and support change based on the person's insights into their relationships with others and the world in which they live. We conclude that interpersonal psychotherapy and intensive short-term dynamic psychotherapy align with that experience, although others are currently being trialled.

Racism, early psychosis and institutional contact: a qualitative study of Indigenous experiences.

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. racism has an important role. This study aimed to use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis. Critical Race Theory informed the methods used. Twenty-three Indigenous participants participated in 4 family focus group interviews and 13 individual interviews, comprising of 9 youth, 10 family members and 4 mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems. This is described across three themes: (1) selective responses based on racial stereotypes, (2) race related risk assessment bias and (3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased coercion and an under resourced Indigenous workforce. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Reimagining eating disorder spaces: a qualitative study exploring Maori experiences of accessing treatment for eating disorders in Aotearoa New Zealand.

BACKGROUND: Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand. METHOD: Kaupapa Maori research methodology was used to ensure the research supported Maori health advancement. Fifteen semi-structured interviews were completed with Maori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whanau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings. RESULTS: Two overarching themes identified systemic and social barriers to accessing treatment for Maori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Maori experiences, and how this makes a place and space of exclusion for Maori and their whanau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy. CONCLUSION: More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whanau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Maori. Attention given to these findings will ensure a place for Maori in specialist eating disorder services in New Zealand.

Eating disorders are at least as common in Maori (Indigenous people of New Zealand) when compared to their non-Maori counterparts, however, a recent study investigating specialist service use data identified lower-than-expected service use for Maori. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support network) to understand the barriers and enablers to accessing treatment. Participants in this study identified both systemic and social barriers to accessing treatment for eating disorders; Systemic barriers included the idiosyncratic use of assessment methods by health practitioners, and inaccessible service locations, including the number of available inpatient beds. While social barriers included the stereotype of what an eating disorder looks like, shame, stigma, and discrimination; support networks were described as both an enabler and barrier to accessing specialist treatment for eating disorders. The findings from this study suggest thorough assessment and early referrals are needed for Maori presenting with disordered eating concerns. Moreover, more education is needed for those working in primary healthcare settings about the diversity of eating disorders to ensure they move beyond the stereotype of what an eating disorder looks like.

Characteristics of effective teletherapy for major depression: A systematic review.

BACKGROUND: People would prefer to have psychotherapy as treatment over medication for major depression. There is evidence that psychotherapy does not require in-person delivery to be effective. Other modes of delivery, such as videoconferencing teletherapy, may make it a more accessible treatment. METHOD: The aim of this review was to identify the characteristics of effective psychotherapy delivered by videoconference for adults in primary care with a primary diagnosis of depression. A quantitative systematic review was conducted and reported according to PRISMA guidelines. RESULTS: There were 8 studies included in the review. The therapies studied were tele problem-solving therapy, behavioural activation and cognitive behavioural therapy. All studies had a medium to high risk of bias. Six were randomized controlled trials, one was a pragmatic retrospective cohort study and one was an open-label design. Four studies found similar outcomes to the in-person comparators, one study found tele problem-solving therapy was more effective than behavioural activation, and one study found cognitive behavioural therapy to be similar to usual care. LIMITATIONS: The search identified only 8 studies. Due to the heterogeneity of outcome measures and comparators, a meta-analysis could not be conducted. CONCLUSIONS: No definitive conclusions can be drawn about the effectiveness of teletherapy in primary care based on this review, however, there is emerging evidence to suggest it has similar outcomes to in-person therapy for people with a primary diagnosis of depression. There is no evidence regarding the superiority of one model of therapy over the others.

Experiences of psilocybin treatment for clinical conditions: A qualitative meta-synthesis.

There is increasing clinical interest in the use of psilocybin. There is emerging evidence of the efficacy of psilocybin for the treatment of a range of clinical conditions. Mental health nurses have a unique set of skills for caring for people who are hallucinating. To expand these skills to meet the developing clinical interest in the therapeutic use of psilocybin, it is helpful to understand the experience from the perspective of the person being treated with psilocybin. A qualitative meta-synthesis was conducted to examine how those with psilocybin described their experiences to identify whether its effects are similar across different health conditions. Ten studies were included in the review. The health conditions studied were cancer, depression, HIV, substance use disorder, smoking cessation and trauma. The synthesis of findings identified three themes that were common across the studies despite the health condition: acceptance, connection and transformation. The review provides helpful insights into how people experience psilocybin and its effects on their health condition.

The experience of 'treatment-resistant' depression: A qualitative meta-synthesis.

While antidepressants may be effective in treating depression for some people, a third of people do not have an improvement in mood after a trial of two different antidepressants for an adequate duration. These people are diagnosed as having 'treatment-resistant' depression which situates the problem as part of their biological or psychological makeup. We conducted a search of studies that examined this problem from the perspective of people whose depression did not improve on antidepressants. Nine studies were included in a qualitative meta-synthesis that identified four themes across these studies: feeling trapped, disconnection, loss of self, and questioning. The participants experienced considerable distress associated with the constant presence of depression in their lives. While antidepressants may help some people, there is a need for more innovative approaches to the treatment of depression. There is a strong argument for trialling appropriate evidence-based psychotherapy before a person is categorized as having treatment-resistant depression. It is perhaps better to describe the issue as inadequate efficacy of antidepressants to situate the problem with the treatment provided rather than with the person.

Evolution of first episode psychosis diagnoses and health service use among young Maori and non-Maori-A New Zealand national cohort study.

AIMS: The validity of diagnostic classification in early psychosis has important implications for early intervention; however, it is unknown if previously found disparities between Maori (Indigenous people of New Zealand) and non-Maori in first episode diagnoses persist over time, or how these differences impact service use. METHODS: We used anonymized routine mental health service data and a previously established cohort of over 2400 13-25-year-old youth diagnosed with FEP between 2009 and 2012, to explore differences in diagnostic stability of psychosis diagnoses, comorbid (non-psychosis) diagnoses, and mental health service contacts between Maori and non-Maori in the five-year period following diagnosis. RESULTS: Differences in schizophrenia and affective psychosis diagnoses between Maori and non-Maori were maintained in the five-year period, with Maori being more likely to be diagnosed with schizophrenia (51% vs. 35%), and non-Maori with bipolar disorder (28% vs. 18%). Stability of diagnosis was similar (schizophrenia 75% Maori vs. 67% non-Maori; bipolar disorder 55% Maori vs. 48% non-Maori) and those with no stable diagnosis at FEP were most likely to move towards a schizophrenia disorder diagnosis in both groups. Maori had a lower rate of diagnosed co-morbid affective and anxiety symptoms and higher rates of continued face to face contact and inpatient admission across all diagnoses. CONCLUSIONS: Indigenous differences in schizophrenia and affective psychosis diagnoses could be related to differential exposure to socio-environmental risk or assessor bias. The lower rate of co-morbid affective and anxiety disorders indicates a potential under-appreciation of affective symptoms in Maori youth with first episode psychosis.

Non-Indigenous privilege in health, justice and social services preceding first episode psychosis: A population-based cohort study.

BACKGROUND: There is evidence of disparities between non-Indigenous and Indigenous incidence of psychotic disorders. Despite these disparities being a clear signpost of the impact of structural racism, there remains a lack of evidence to target institutional factors. We aimed to investigate non-Indigenous and Indigenous differences in government service use prior to first episode diagnosis as a means of identifying points of intervention to improve institutional responses. METHODS: We used a previously established national New Zealand cohort of 2385 13 to 25-year-old youth diagnosed with psychosis between 2009 and 2012 and a linked database of individual-level multiple government agency administration data, to investigate the differences in health, education, employment, child protection and criminal-justice service use between non-Indigenous (60%) and Indigenous youth (40%) in the year preceding first episode diagnosis. Further comparisons were made with the general population. RESULTS: A high rate of health service contact did not differ between non-Indigenous and Indigenous youth (adjusted rate ratio 1.0, 95% confidence interval [0.9, 1.1]). Non-Indigenous youth had higher rates of educational enrolment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and employment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and were 40% less likely to have contact with child protection services (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.8]) and the criminal-justice system (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.7]). Both first episode cohorts had a higher risk of criminal justice contact compared to the general population, but the difference was greater for non-Indigenous youth (risk ratio 3.0, 95% confidence interval [2.7, 3.4] vs risk ratio 2.0, 95% confidence interval [1.8, 2.2]), explained by the lower background risk. INTERPRETATION: The results indicate non-Indigenous privilege in multiple sectors prior to first episode diagnosis. Indigenous-based social disparities prior to first episode psychosis are likely to cause further inequities in recovery and will require a response of health, education, employment, justice and political systems.

Comparison of patients' and staff's perspectives on the causes of violence and aggression in psychiatric inpatient settings: An integrative review.

WHAT IS KNOWN ON THE SUBJECT?: Aggression and violence are persistent problems in psychiatric inpatient units. Violence preventive factors have been identified from both staff's and patients' perspectives. Violent and aggressive inpatient incidents have not been adequately explained in research and reviews to date. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review is novel in that it provides a comparison of patients' and staff's perspectives and identified that these differ and were influenced by factors attributable to the inpatient culture. The one contributory factor both agreed upon was the role of staff's interpersonal skills in either exacerbating or de-escalating aggression and violence. The inpatient culture was found to engender differing perceptions of most contributory factors to violence and aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While staff's interpersonal skills were identified as a primary influence on whether their interaction with patients contributed to aggression and violence, this was shaped by the inpatient environment's culture. Patient-centred interactional skills need to focus on the patients' needs for respect and active participation rather than engendering feelings of disrespect or coercion. Patient-centred communication skills that demonstrate an understanding of the patient's experience in the inpatient environment need to be core skills for mental health nurses. ABSTRACT: Introduction High rates of aggression and violence are a persistent problem in inpatient mental health environments. A comparison of staff's and patients' perceptions of the causes may provide novel insights. Aim This review aimed to compare patients' and staff's perspectives on the causes of aggression and violence in inpatient environments. Method An integrative review of the literature was conducted with a search of Ovid (Medline, Embase, PsycINFO) databases and manual searching. Results Thirty articles met criteria for inclusion. Interactions prior to aggressive or violent incidents were characterized by patients as disrespectful and coercive, and by staff as indicative of the patient's mental state or personality. Both groups identified the importance of patient-centred communication skills. Discussion The review identified that patients and staff have differing perspectives on the causes of violence and aggression. There was an interactional dynamic between staff and patients that was shaped by the culture of the inpatient setting. Implications for Practice Understanding how the inpatient culture plays a role in shaping a dynamic between patients and staff and developing communication skills that acknowledge this may help reduce violence and aggression in inpatient settings.

Exploring indigenous ethnic inequities in first episode psychosis in New Zealand - A national cohort study.

INTRODUCTION: First episode psychosis (FEP) disproportionately affects rangatahi (young) Maori, the Indigenous people of New Zealand, but little is known about factors contributing to this inequity. This study describes a cohort of rangatahi Maori and young non-Maori with FEP, and explores ethnic differences in incidence rates, and the contribution of deprivation, urbanicity and substance use. METHODS: Maori and young non-Maori, aged 13-25 at the time of the first recorded psychosis-related diagnoses, were identified from within Statistics NZ's Integrated Data Infrastructure (IDI), between 2009 and 2012. To estimate age-standardised FEP incidence rates, the population-at-risk was estimated using IDI-based usual resident population estimates for 2009-2012, stratified by ethnicity and single year of age. Poisson regression models were used to estimate ethnic differences in FEP incidence adjusted for age, gender, deprivation, and urban-rural area classification. RESULTS: A total of 2412 young people with FEP (40% Maori, 60% non-Maori) were identified. Maori were younger, and more likely to live in deprived and rural communities and be diagnosed with schizophrenia. Substance induced psychosis was uncommon. The unadjusted age-standardised FEP incidence rate ratio was 2.48 (95% CI: 2.29-2.69) for rangatahi Maori compared with young non-Maori. While adjusting for age, sex, deprivation and urban rural area classification reduced ethnic differences in incidence, rangatahi Maori were still more than twice as likely to have been diagnosed with FEP compared to young non-Maori. CONCLUSIONS: This study confirms previous findings of elevated rates of psychosis among rangatahi Maori. The difference in rates between Maori and non-Maori were attenuated but remained after adjustment for deprivation and urbanicity.

Eating disorders in New Zealand: Implications for Maori and health service delivery.

OBJECTIVE: Lifetime prevalence rates in Te Rau Hinengaro (The New Zealand Mental Health Survey) suggest eating disorders are at least as common in the Maori population as the non-Maori population, yet little is known at a population level about those accessing specialist mental health treatment for eating disorders in New Zealand. The aim of this study was to describe the population undergoing specialist mental health treatment for eating disorders and compare Maori and non-Maori clinical characteristics and service use. METHOD: This study uses the Programme for the Integration of Mental Health Data data set, managed by the New Zealand Ministry of Health to describe the characteristics of people with eating disorders and their use of specialist mental health services from 2009 to 2016. RESULTS: There were 3,835 individuals with a diagnosed eating disorder who had contact with specialist mental health services in this time period, 7% of whom were Maori. Within the cohort, Maori had a higher prevalence for a bulimia nervosa diagnosis, fewer diagnosed with anorexia nervosa, and a higher prevalence of other psychiatric comorbidity than non-Maori. DISCUSSION: There is discrepancy between the proportion of service users accessing specialist mental health services who are Maori and the assessed crude prevalence of eating disorders for Maori in national estimates. Once Maori are in specialist services; however, their use of services is comparable to non-Maori. Further research is needed to highlight the experiences of those Maori with eating disorders and address barriers to accessing services for Maori with eating disorders.

Is there systemic bias for Maori with eating disorders? A need for greater awareness in the healthcare system.

The New Zealand Mental Health Survey, Te Rau Hinengaro, indicated that eating disorders are at least as common in Maori as non-Maori, which is consistent with international findings that eating disorders exist in other indigenous and ethnic minority groups. Specific factors may be relevant to the development and treatment of eating disorders in the Maori population. We suggest this may include differential exposure to risk factors, the impact of acculturation, changing body image ideals and systemic bias reducing access to treatment and research participation. However, an absence of high-quality research regarding eating disorders in Maori makes it difficult to be certain about this. We suspect that Maori do not receive treatment in specialist eating disorders services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Maori with eating disorders is likely to be systemic bias. Urgent attention to this area of research is required.

Sociodemographic, environmental characteristics and comorbidities of older adults with schizophrenia who access community health service support: A national cross-sectional study.

OBJECTIVES: Schizophrenia is a serious and chronic mental illness known to have broad ranging impacts for individuals across the lifespan, yet research on the disease in older adults is sparse. This study provides a profile of the sociodemographic, environmental and diagnostic characteristics of older community residents with schizophrenia using a national database. METHODS: A cross-sectional sample of individuals who underwent community needs assessment using the standardised Home Care International Residential Assessment Instrument between 1 September 2012 and 31 January 2016 was utilised. Sociodemographic, diagnostic, and social and environmental variables were measured for individuals with a diagnosis of schizophrenia and compared to those without a diagnosis of schizophrenia. Statistical investigations employed bivariable and multivariable logistic regression models. RESULTS: A total sample of 71,859 was eligible and 517 (0.7%) had a diagnosis of schizophrenia. The majority of the sociodemographic variables were statistically associated with schizophrenia in the adjusted analysis, except for ethnicity ( p = 0.35). Nearly all the measured social and environmental variables were adversely associated with having a diagnosis of schizophrenia, such as living in squalid conditions (adjusted odds ratio = 2.16; 95% confidence interval = [1.42, 3.28]). Participants with schizophrenia were significantly more likely to be diagnosed with all assessed psychiatric comorbidities ( p < 0.001) and diabetes mellitus ( p = 0.002), whereas coronary heart disease ( p = 0.001) and other physical comorbidities ( p = 0.001) were found at significantly lower rates. CONCLUSION: The profile of schizophrenia found here suggests some subtle differences in the demographic profile and distribution of medical comorbidities in the older population with schizophrenia. The results also suggest that this group continues to experience social disadvantage into old age. This requires the attention of policy-makers to ensure that services are tailored to the high social needs of these individuals.

Suicide prevention in mental health services: A qualitative analysis of coroners' reports.

Suicide is a major concern for mental health nurses because of its clear correlation with mental illness. In New Zealand, coroners investigate all deaths that appear to be a result of suicide, and provide reports to mental health services (MHS). The aim of the present study was to investigate coronial recommendations to MHS in relation to suicide prevention and to examine clinical and family responses to these. The present study was a three-phase design: (i) analysis of coroners' recommendations related to suicide in MHS; (ii) interviews with clinicians for their response to the recommendations; and (iii) interviews with individuals working with families of consumers of MHS for their responses in relation to family-related recommendations. A qualitative content analysis was conducted on the recommendations from coroners, the interviews with clinical leaders, and the focus group for family workers. Coroners recommended that MHS should implement suicide-prevention strategies that would facilitate improved communication, risk containment, service delivery, and family involvement. Clinicians agreed with most recommendations, apart from those related to risk containment. Family workers endorsed the coronial perspective that family inclusion in MHS was suboptimal. Coroners, MHS, and mental health nurses need to consider the latest clinical evidence for suicide prevention. However, given the complexity of factors that influence suicide, it is important to be realistic about MHS role in preventing suicide, but ensure that MHS provide interventions for which there is evidence, including facilitating family participation and providing access to psychotherapies.

Clinical responsibility, accountability, and risk aversion in mental health nursing: a descriptive, qualitative study.

A number of recent, highly-publicized, perceived health-care service failures have raised concerns about health professionals' accountabilities. Relevant to these concerns, the present study sought to examine how mental health nurses understood clinical responsibility and its impact on their practice. A descriptive, qualitative design was used, and a convenience sample of 10 mental health nurses was recruited from specialist inpatient and outpatient mental health settings in Canterbury, New Zealand. Data were collected using semistructured interviews, and the transcriptions were analysed using an inductive, descriptive approach. Three major themes were identified: being accountable, fostering patient responsibility, and shifting responsibility. Being accountable involved weighing up patients' therapeutic needs against the potential for blame in an organizational culture of risk management. Fostering patient responsibility described the process of deciding in what situations patients could take responsibility for their behaviour. Shifting responsibility described the culture of defensive practice fostered by the organizational culture of risk aversion. The present study highlighted the challenges mental health nurses experience in relation to clinical responsibility in practice, including the balancing required between the needs of patients, the needs of the organization, and the perceived need for self-protection.