Delayed discharge in inpatient psychiatric care: a systematic review.

BACKGROUND: Delayed discharge is problematic. It is financially costly and can create barriers to delivering best patient care, by preventing return to usual functioning and delaying admissions of others in need. This systematic review aimed to collate existing evidence on delayed discharge in psychiatric inpatient settings and to develop understanding of factors and outcomes of delays in these services. METHODS: A search of relevant literature published between 2002 and 2022 was conducted on Pubmed, PsycInfo and Embase. Studies of any design, which published data on delayed discharge from psychiatric inpatient care in high income countries were included. Studies examining child and adolescent, general medical or forensic settings were excluded. A narrative synthesis method was utilised. Quality of research was appraised using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Eighteen studies from England, Canada, Australia, Ireland, and Norway met the inclusion criteria. Six main reasons for delayed discharge were identified: (1) accommodation needs, (2) challenges securing community or rehabilitation support, (3) funding difficulties, (4) family/carer factors, (5) forensic considerations and (6) person being out of area. Some demographic and clinical factors were also found to relate to delays, such as having a diagnosis of schizophrenia or other psychotic disorder, cognitive impairment, and increased service input prior to admission. Being unemployed and socially isolated were also linked to delays. Only one study commented on consequences of delays for patients, finding they experienced feelings of lack of choice and control. Four studies examined consequences on services, identifying high financial costs. CONCLUSION: Overall, the findings suggest there are multiple interlinked factors relevant in delayed discharge that should be considered in practice and policy. Suggestions for future research are discussed, including investigating delayed discharge in other high-income countries, examining delayed discharge from child and forensic psychiatric settings, and exploring consequences of delays on patients and staff. We suggest that future research be consistent in terms used to define delayed discharge, to enhance the clarity of the evidence base. REVIEW REGISTRATION NUMBER ON PROSPERO: 292515. DATE OF REGISTRATION: 9th December 2021.

When the Penny Drops: Understanding how social class influences speciality careers in the UK medical profession.

In the UK, the medical profession is socially exclusive and socially stratified as doctors from more advantaged backgrounds are more likely to train for specialities with more competitive entry. However, in research to date the causes and consequences of social stratification have been overlooked. We explore this subject here, drawing on a qualitative study comprising in-depth interviews with 30 medical students and doctors from less advantaged socio-economic backgrounds negotiating medical school and early careers. Using Bourdieu's 'theory of practice' we show how socialisation in the family and at school influences how aspirant medics from less advantaged backgrounds view the world, suggesting some inclination towards more community orientated careers, which may be less competitive. However, these tendencies are encouraged as they lack stocks of social, economic and cultural capital, which are convertible to power and position in the field. While allowing for both choice and constraint our core argument is that speciality outcomes are sometimes inequitable and potentially inefficient, as doctors from more advantaged backgrounds have privileged access to more competitive careers for reasons not solely related to ability or skill. Our main theoretical contribution is to literature in the sociology of medical education where ours is the first study to open-up the 'black box' of causal factors connecting medical students' resources on entering the field of education and training with speciality outcomes, though our findings also have important implications for practitioners, the profession and for patients. We discuss the implications for safe and effective healthcare and how this informs directions for future research.

Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in England.

BACKGROUND: An invisible threat has visibly altered the world. Governments and key institutions have had to implement decisive responses to the danger posed by the coronavirus pandemic. Imposed change will increase the likelihood that alternative explanations take hold. In a proportion of the general population there may be strong scepticism, fear of being misled, and false conspiracy theories. Our objectives were to estimate the prevalence of conspiracy thinking about the pandemic and test associations with reduced adherence to government guidelines. METHODS: A non-probability online survey with 2501 adults in England, quota sampled to match the population for age, gender, income, and region. RESULTS: Approximately 50% of this population showed little evidence of conspiracy thinking, 25% showed a degree of endorsement, 15% showed a consistent pattern of endorsement, and 10% had very high levels of endorsement. Higher levels of coronavirus conspiracy thinking were associated with less adherence to all government guidelines and less willingness to take diagnostic or antibody tests or to be vaccinated. Such ideas were also associated with paranoia, general vaccination conspiracy beliefs, climate change conspiracy belief, a conspiracy mentality, and distrust in institutions and professions. Holding coronavirus conspiracy beliefs was also associated with being more likely to share opinions. CONCLUSIONS: In England there is appreciable endorsement of conspiracy beliefs about coronavirus. Such ideas do not appear confined to the fringes. The conspiracy beliefs connect to other forms of mistrust and are associated with less compliance with government guidelines and greater unwillingness to take up future tests and treatment.

Anticipatory pleasure in current psychosis: Cognitive and emotional correlates.

Anticipation of pleasure - a key aspect of hedonic experience - is a motivating factor for engaging in activities. Low levels of anticipatory pleasure and activity are found in individuals with psychosis. Cognitive factors (e.g., working memory and IQ) have been a focus of explanation for anticipation of pleasure in psychosis. However, cognitive factors do not fully account for such difficulties. It is plausible that emotional factors (e.g., depression, self-beliefs) also contribute. We examined anticipatory pleasure in relation to cognitive and emotional processes in patients with current psychosis. 128 patients with persecutory delusions in the context of non-affective psychosis completed assessments of anticipatory pleasure, cognitive functioning, emotional processes, and activity. Lower anticipatory pleasure was significantly associated with depression, insomnia, negative-self beliefs, suicidal ideation, poorer psychological wellbeing, and paranoia-related avoidance. There were no significant associations with working memory, physical activity, or meaningful activity.  Emotional factors may play a more significant role than cognitive difficulties in the experience of anhedonia in psychosis. However, the cross-sectional design precludes causal inferences. Future research should examine whether, for example, improving self-concept or reducing paranoia-related avoidance leads to improvement in anticipatory pleasure in patients with psychosis.

Paranoia in patients attending child and adolescent mental health services.

OBJECTIVE: Paranoia may be particularly prevalent during adolescence, building on the heightened social vulnerabilities at this age. Excessive mistrust may be corrosive for adolescent social relationships, especially in the context of mental health disorders. We set out to examine the prevalence, symptom associations, and persistence of paranoia in a cohort of young people attending child and adolescent mental health services. METHOD: A total of 301 patients (11-17 years old) completed measures of paranoia, affect, peer difficulties and behavioural problems. Clinicians also rated each participant's psychiatric symptoms. Patterns of association were examined using linear regressions and network analyses. In total, 105 patients repeated the measures several months later. RESULTS: Most of the adolescents had affective disorders (n = 195), self-harm/suicidality (n = 82), or neurodevelopmental conditions (n = 125). Few had suspected psychosis (n = 7). Rates of paranoia were approximately double compared with previous reports from the general population. In this patient sample, 35% had at least elevated paranoia, 15% had at least moderate paranoia, and 6% had high paranoia. Paranoia had moderate associations with clinician-rated peer difficulties, self-harm, and trauma, and small associations with clinician-rated social anxiety, depression, generalised anxiety, and educational problems. Network analyses showed paranoia had the strongest unique relationship with peer difficulties. Paths from peer difficulties to anxiety, self-harm, post-traumatic stress disorder symptoms, and behavioural problems were all via paranoia. Both self-harm and post-traumatic stress disorder were solely associated with paranoia in the network. Paranoia remained persistent for three-quarters and was associated with greater psychological problems over time. CONCLUSION: Paranoia is relatively common and persistent across a range of clinical presentations in youth. When paranoia occurs alongside emotional problems, important peer interactions may be adversely affected. Wider consideration of paranoia in adolescent patients is needed.

The assessment of paranoia in young people: Item and test properties of the Bird Checklist of Adolescent Paranoia.

BACKGROUND: Precise assessment tools for psychotic experiences in young people may help identify symptoms early and facilitate advances in treatment. In this study we provide an exemplar - with a paranoia scale for youth - for improving measurement precision for psychotic experiences using item response theory (IRT). We evaluate the psychometric properties of the new measure, test for measurement invariance, and assess its potential for computerised adaptive testing (CAT). METHOD: The 18-item Bird Checklist of Adolescent Paranoia (B-CAP) was completed by 1102 adolescents including 301 patients with mental health problems and 801 from the general population. After excluding outliers (n = 10), IRT was used to examine item properties, test reliability, and measurement invariance. The properties of an adaptive B-CAP were assessed using a simulation of 10,000 responses. RESULTS: All B-CAP items were highly discriminative (a = 1.14-2.77), whereby small shifts in paranoia led to a higher probability of item endorsement. Test reliability was high (a > 0.90) across a wide range of paranoia severity (θ = -0.45-3.36), with the greatest precision at elevated levels. All items were invariant for gender, age, and population groups. The simulated adaptive B-CAP performed with high accuracy and required only 5-6 items at higher levels of paranoia severity. CONCLUSIONS: The B-CAP is a reliable assessment tool with excellent psychometric properties to assess both non-clinical and clinical levels of paranoia in young people, with potential as an efficient adaptive test. In future, these approaches could be used to develop a multidimensional CAT to assess the full range of psychotic experiences in youth.

The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors.

BACKGROUND: The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. AIMS: To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors - identified from a cognitive model - before delusion onset. METHOD: A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. RESULTS: Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. CONCLUSIONS: Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. DECLARATION OF INTEREST: None.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'.

BACKGROUND: There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. AIMS: To systematically assess the occurrence of voice content regarding appearance and identify correlates. METHOD: Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. RESULTS: Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. CONCLUSIONS: Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia. DECLARATION OF INTEREST: None.