A critical review of undergraduate education and teaching in forensic psychiatry.

BACKGROUND: Although forensic psychiatry is recognised as a full medical speciality in the UK, training in it is not routinely offered to medical students. With growth both in forensic psychiatry and availability of medical school places, it is a good time to explore the nature and quality of experience already available. AIMS: 1. To map the literature against the guideline for reporting evidence-based practice educational interventions and teaching checklist. 2. To critically review research and scholarship. 3. To identify gaps in evidence-based education for medical students in forensic psychiatry. METHOD: A systematic search of three bibliographic databases from inception to December 2021 was undertaken using keywords related to medical students and forensic psychiatry between December 2021 and March 2022. The search was supplemented by citation and hand searching. RESULTS: Eight articles were identified. Collectively, they suggest that education and teaching were implemented at a local level and not linked to theories of learning. Exposure to forensic psychiatry stimulated positive attitudes, which amplified interest in psychiatry. There was insufficient evidence to determine optimal undergraduate education and teaching practice in forensic psychiatry. CONCLUSIONS: Forensic psychiatry appears to have much to offer the medical undergraduate as part of core learning in psychiatry, including universal skills and knowledge such as ethical decision-making and handling emotions. There appears to be considerable opportunity for education, teaching and research innovation in undergraduate education and teaching in forensic psychiatry. Interesting areas for development include simulated and coproduced education.

Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis.

Background: Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances. Aim: The aim was to identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work. Objectives: The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes. Design: This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory. Main outcome: The main outcome was to explain context, mechanisms and outcomes in adult community mental health crisis care. Data sources: Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts. Review methods: A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. Results: Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve. Strengths and limitations: Strengths include the identification of mechanisms for effective inter-agency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity. Conclusions: Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion. Future work: Further work might explore inter-agency models of crisis delivery, particularly in rural communities. Future work could focus on evaluating outcomes across crisis care provider agencies and include evaluation of individual, as well as service-level, outcomes. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research. Study registration: The study is registered as PROSPERO CRD42019141680. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information.

A mental health crisis can be traumatic for individuals and families. There are a lot of different agencies delivering crisis care. This can make getting the right help from services difficult, confusing and slow. It is not clear which services work best or who they work best for. This research explored community mental health crisis services for adults. We focused on what is working, who it is working for and in what situations it is working. Service users, carers, mental health professionals and service managers formed an 'expert stakeholder group' to guide the project by helping the researchers make sense of what we learned. We gathered information from research reports, other documents and interviews with experts (i.e. service users, carers, professionals, managers). We focused on three questions: How can services make sure that people in crisis can get the right help, quickly? What makes crisis care compassionate? Does it help if different crisis services work together? Community crisis services are most compassionate and effective when staff from different organisations share information. When leaders of crisis care help staff to work together across services, they find better ways to help people. Close working across teams gives professionals a better understanding of what other services do and makes it easier for them to give people the right help at the right time. When leaders are kind and supportive to staff, they feel better at work and provide better crisis care. It would be useful to explore if the most effective crisis services are the same ones that service users like best. We need to know more about mental health triage, inter-agency working and telehealth. Our project did not explore diversity, but this is an important topic to investigate.

Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis.

Mental health crises cause significant distress and disruption to the lives of individuals and their families. Community crisis care systems are complex, often hard to navigate and poorly understood. This realist evidence synthesis aimed to explain how, for whom and in what circumstances community mental health crisis services for adults work to resolve crises and is reported according to RAMESES guidelines. Using realist methodology, initial programme theories were identified and then tested through iterative evidence searching across 10 electronic databases, four expert stakeholder consultations and n = 20 individual interviews. 45 relevant records informed the three initial programme theories, and 77 documents, were included in programme theory testing. 39 context, mechanism, outcome configurations were meta-synthesized into three themes: (1) The gateway to urgent support; (2) Values based crisis interventions and (3) Leadership and organizational values. Fragmented cross-agency responses exacerbated staff stress and created barriers to access. Services should focus on evaluating interagency working to improve staff role clarity and ensure boundaries between services are planned for. Organizations experienced as compassionate contributed positively to perceived accessibility but relied on compassionate leadership. Attending to the support needs of staff and the proximity of leaders to the front line of crisis care are key. Designing interventions that are easy to navigate, prioritize shared decision-making and reduce the risk of re-traumatizing people is a priority.

How do general hospitals respond to people diagnosed with a personality disorder who are distressed: A qualitative study of clinicians in mental health liaison.

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with a personality disorder might be more likely to have physical health problems and be admitted to the hospital. Treatment in hospitals might be complicated by mental health crises or self-injury, and barriers to NHS care may increase the risk of developing further illness with serious consequences. Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Thirteen clinicians working in mental health liaison in the general hospital were interviewed as part of a sequence of research studies. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: This study identified unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in general hospitals. People with a "personality disorder" diagnosis were discriminated against and over- and under-medicated. Mental health liaison clinicians reported limited understanding and skills among general hospital clinicians. People working in general hospitals were fearful of the "personality disorder" diagnosis. Poor care was accepted because general hospital clinicians did not consider themselves to be "mental health trained." WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Clinicians working in mental health liaison need credible knowledge of mental and physical health and medicines. Capability, influence, and high-level interpersonal skills are needed to successfully work across mental health services and the general hospital. More advanced and consultant-level nursing roles in more mental health liaison teams are needed to strengthen this specialist workforce. ABSTRACT: Introduction Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Aim Qualitative telephone interviews were undertaken to explore the views and perspectives of clinicians working in mental health liaison in this final strand of a mixed methods explanatory sequential study. Method Participants were recruited via social media and professional networks by snowball sampling. Data were analysed using a framework approach. Results Four themes were identified: knowledge, understanding, skills, and discriminatory practice; alliances, diplomacy, care, and treatment of people diagnosed with a "personality disorder"; achieving parity of esteem in a disparate healthcare system; and organizational stress, mismatched expectations, and service led decision-making. Discussion There were unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in the general hospital. People were discriminated against and routinely over- and under-medicated. Implications for practice Clinicians working in mental health liaison need capacity for partnership working, clinical capability spanning mental and physical health, credibility and influence and high-level interpersonal skills to address the entrenched discrimination of people diagnosed with a "personality disorder."

A mixed methods study of the healthcare received by patients diagnosed with a personality disorder on acute general hospital wards.

AIM: The study examined concurrent mental and physical healthcare received by patients diagnosed with a personality disorder on acute general hospital wards. The specific objectives were (i) to conduct a web based cross sectional survey and (ii) to explore experiences and perspectives with a subsection of the survey sample, using telephone interviews. DESIGN: A convergent parallel mixed methods design, which comprised a web-based cross sectional survey (n = 65) with embedded qualitative telephone interviews (n = 12). Participants were social media users, with a self-reported diagnosis of personality disorder, admitted to an acute general hospital in the UK in the previous 2 years. METHODS: Participants were recruited on social media between May 2017 and August 2017 by snowballing. Mixed data were integrated at the stage of analysis using a framework approach. Findings are reported thematically. RESULTS: Most of the participants surveyed (94%, n = 61) reported distress during admission to the acute general hospital. However, the findings indicated the hospital environment was not conducive to mental health. Four interrelated themes were identified and related to: patient distress; the workforce; service delivery; and service design. CONCLUSION: Findings indicated that patients with a personality disorder diagnosis received disadvantaged healthcare, might be at considerable risk of treatment noncompletion, and were languishing in the gaps between mental and physical health services. IMPACT: This is one of the first studies to collect primary data on the concurrent mental and physical healthcare received by patients diagnosed with a personality disorder on acute general hospital wards. Ad hoc training and education focused on raising awareness of 'personality disorder' would not seem sufficient to address the deficits. This research may be of interest to people who use mental health services, acute general hospital and liaison clinicians, hospital managers and researchers.