Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review.

Introduction: Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods: A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results: We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion: Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration: [Prospero], identifier [CRD42021284959].

Femicide trends at the start of the 21st. century: Prevalence, risk factors and national public health actions.

Lethal violence requires a gender-based analysis which recognises that femicide is different from homicide in many ways. Structural factors such as national income and wealth equality together with government policies may influence the scale of the problem globally. This study is an original attempt to examine associations between femicide rates, these structural factors and national action plans using a longitudinal design. Data from two international surveys were combined to examine anti-femicide actions (n = 133 countries) and temporal femicide prevalence trends (n = 66 countries) in the context of national income and wealth inequality factors. The United Nations Survey of Crime Trends and Operations of Criminal Justice Systems was used to estimate femicide rates per country 2003-2014 and the World Health Organisation Global Status Report on Violence Prevention provided data on policy initiatives in place by 2014. Results indicate that femicide rates decreased by 32% worldwide but increased by 26% in low- and medium-income countries. The structural factors of low income and high inequality were significantly negatively associated with the 2014 femicide rate. Structural factors must be addressed alongside policy and legal initiatives if significant gains are to be made toward eradicating violence against women and girls.

Longitudinal investigation of the presence of different trajectories and associated health and socio-economic determinants, for participants who report suicidal ideation within a community-based public health survey.

OBJECTIVE: Given the paucity of evidence-based research investigating different suicidal ideation profiles and trajectories, this project sought to investigate health and socio-economic factors associated with the presence of suicidal ideation and changes in ideation over time. DESIGN: Longitudinal cohort design, using logistic regression analysis. SETTING: A public health survey was administered at two timepoints in a community setting across the North West of England. In the 2015/2016 survey, participants were recruited from high (n=20) and low (n=8) deprivation neighbourhoods. In the 2018 survey, only the 20 high-deprivation neighbourhoods were included. PARTICIPANTS: 4287 people were recruited in 2015/2016 and 3361 were recruited in 2018. The 2018 sample was subdivided into those who responded only in 2018 (n=2494: replication sample) and those who responded at both timepoints (n=867: longitudinal sample). PRIMARY OUTCOME MEASURES: Suicide ideation was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire instrument. RESULTS: The prevalence of suicidal ideation was 11% (n=454/4319) at 2015/2016 and 16% (n=546/3361) at 2018.Replication study results highlighted: persistent debilitation from physical ill health and/or medication side effects; demographic factors (ie, middle-aged, single or never married); and personal coping strategies (ie, smoking) as risk factors for suicidal ideation. A static/improved financial position and high levels of empathy were protective factors.Longitudinal study results confirmed three suicidal ideation trajectories: 'onset', 'remission' and 'persistence'. Similar findings to the replication study were evidenced for the onset and persistence trajectories. Persistent suicidal ideation was synonymous with higher levels of practical support which may correspond to the higher levels of debilitation and functional disability reported within this group. Remission was characterised by fewer debilitating factors and higher levels of self-agency. CONCLUSION: A greater appreciation of the heterogeneity of suicidal trajectories should lead to the implementation of broad clinical assessments and targeted interventions.

Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: Protocol for a realist review.

INTRODUCTION: The use of restrictive practices has significant adverse effects on the individual, care providers and organisations. This review will describe how, why, for whom, and in what circumstances approaches used by healthcare organisations work to prevent and reduce the use of restrictive practices on adults with learning disabilities. METHODS AND ANALYSIS: Evidence from the literature will be synthesised using a realist review approach - an interpretative, theory-driven approach to understand how complex healthcare approaches work in reducing the use of restrictive practices in these settings. In step 1, existing theories will be located to explore what approaches work by consulting with key topic experts, holding consultation workshops with healthcare professionals, academics, and experts by experience, and performing an informal search to help develop an initial programme theory. A systematic search will be performed in the second step in electronic databases. Further searches will be performed iteratively to test particular subcomponents of the initial programme theory, which will also include the use of the CLUSTER approach. Evidence judged as relevant and rigorous will be used to test the initial programme theory. In step three, data will be extracted and coded inductively and deductively. The final step will involve using a realist logic of analysis to refine the initial programme theory in light of evidence. This will then provide a basis to describe and explain what key approaches work, why, how and in what circumstances in preventing and reducing the use of restrictive practices in adults with learning disabilities in healthcare settings. RESULTS: Findings will be used to provide recommendations for practice and policymaking. REGISTRATION: In accordance with the guidelines, this realist review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 4th December 2019 (CRD42019158432).

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK.

BACKGROUND: The use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called "No Force First" within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation. METHODS: The study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the "intervention" group comprising all incidents on these wards during the 24 months post-implementation (2018-2019) (n = 6,551) and the "control" group comprising all incidents in the 24 months preceding implementation (2015-2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates. RESULTS: A significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77-0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91-6.23) and post-intervention (aPR = 9.09, 95% CI 5.09-16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients). CONCLUSIONS: This is a key study reporting the positive impact that organisational models and guides such as "No Force First" can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

Negotiating organisational blame to foster learning: Professionals' perspectives about Domestic Homicide Reviews.

Domestic Homicide Reviews (DHRs) are a statutory requirement in England and Wales, conducted when somebody aged 16 and over dies from violence, abuse or neglect by a relative, intimate partner or member of the same household. While key aims of DHRs are to identify recommendations and lessons learned to eventually prevent further domestic homicides, there is limited evidence globally regarding the extent to which these are followed up or make a difference. This paper explores the barriers and facilitators to the conduct and impact of DHRs to enhance their learning potential. It is based on nineteen qualitative interviews with professionals involved in the DHR process across five Safeguarding Boards in Wales and fourteen Community Safety Partnerships in the North-West of England, UK. Findings are presented thematically under four section headings: upskilling and democratising the review process; family and friends' involvement; negotiating organisational blame to foster learning; and actioning and auditing recommendations. It is suggested that organisational learning cannot be achieved without accepting organisational responsibility, which could be interpreted as blame. The role and skills of the Chair are perceived as key to ensure a safe, evidence-based, transparent and learning-focused DHR process. Developing and actioning recommendations may challenge longstanding prejudices. Promoting the role of families/survivor networks and professionals on an equal footing would support a more democratic process. Learning could be enhanced by thematising recommendations and proactively using lessons from one area to inform another. Participants called for appropriate central regulation and accountability to support the action of recommendations.

Does neighbourhood identification buffer against the effects of socioeconomic disadvantage on self-harm?

BACKGROUND: Socioeconomic disadvantage and lack of group belonging (i.e., social identity) have been linked to poor mental health. However, no research has investigated the relationship between neighbourhood identity and self-harm, nor whether identifying with one's neighbourhood can mitigate the effects of economic stress on self-harm. METHODS: Pre-registered secondary data analysis of a large (N = 3412) community health survey conducted in disadvantaged areas of North West England. RESULTS: Despite the sample having a relatively high and therefore restricted level of disadvantage, individual and geographic indicators of disadvantage, as well as neighbourhood identification, were unique and strong predictors of self-harm thoughts and behaviours across several analyses. Specifically, experiencing disadvantage and disidentification predicted significantly higher odds of self-harm and self-harm thoughts. No consistent interactive effects emerged. LIMITATIONS: The cross-sectional design limits firm conclusions regarding causal effects of neighbourhood identity and disadvantage on self-harm. However, causal direction is supported by past research and theory. The data is self-report, which is subject to response bias. The sample was also recruited from a region of the UK with low numbers of residents from ethnic minority backgrounds. CONCLUSIONS: The results are consistent with past research indicating an association between social identity and better mental health, but for the first time extend these effects to self-harm. The findings demonstrate the importance of considering social and economic factors when attempting to prevent suicide and understand and treat self-harm thoughts.

Investigation to identify individual socioeconomic and health determinants of suicidal ideation using responses to a cross-sectional, community-based public health survey.

OBJECTIVES: To address a gap in knowledge by simultaneously assessing a broad spectrum of individual socioeconomic and potential health determinants of suicidal ideation (SI) using validated measures in a large UK representative community sample. DESIGN: In this cross-sectional design, participants were recruited via random area probability sampling to participate in a comprehensive public health survey. The questionnaire examined demographic, health and socioeconomic factors. Logistic regression analysis was employed to identify predictors of SI. SETTING: Community setting from high (n=20) and low (n=8) deprivation neighbourhoods across the North West of England, UK. PARTICIPANTS: 4319 people were recruited between August 2015 and January 2016. There were 809 participants from low-deprivation neighbourhoods and 3510 from high-deprivation neighbourhoods. The sample comprised 1854 (43%) men and 2465 (57%) women. PRIMARY OUTCOME MEASURES: SI was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire-9 instrument. RESULTS: 454 (11%) participants reported having SI within the last 2 weeks. Model 1 (excluding mental health variables) identified younger age, black and minority ethnic (BME) background, lower housing quality and current smoker status as key predictors of SI. Higher self-esteem, empathy and neighbourhood belonging, alcohol abstinence and having arthritis were protective against SI. Model 2 (including mental health variables) found depression and having cancer as key health predictors for SI, while identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ) and BME were significant demographic predictors. Alcohol abstinence, having arthritis and higher empathy levels were protective against SI. CONCLUSIONS: This study suggests that it could be useful to increase community support and sense of belonging using a public health approach for vulnerable groups (e.g. those with cancer) and peer support for people who identify as LGBTQ and/or BME. Also, interventions aimed at increasing empathic functioning may prove effective for reducing SI.

Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users.

BACKGROUND: Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data. OBJECTIVE: This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies. METHODS: Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected. RESULTS: Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality. CONCLUSIONS: To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting.

Testing Suicide Risk Prediction Algorithms Using Phone Measurements With Patients in Acute Mental Health Settings: Feasibility Study.

BACKGROUND: Digital phenotyping and machine learning are currently being used to augment or even replace traditional analytic procedures in many domains, including health care. Given the heavy reliance on smartphones and mobile devices around the world, this readily available source of data is an important and highly underutilized source that has the potential to improve mental health risk prediction and prevention and advance mental health globally. OBJECTIVE: This study aimed to apply machine learning in an acute mental health setting for suicide risk prediction. This study uses a nascent approach, adding to existing knowledge by using data collected through a smartphone in place of clinical data, which have typically been collected from health care records. METHODS: We created a smartphone app called Strength Within Me, which was linked to Fitbit, Apple Health kit, and Facebook, to collect salient clinical information such as sleep behavior and mood, step frequency and count, and engagement patterns with the phone from a cohort of inpatients with acute mental health (n=66). In addition, clinical research interviews were used to assess mood, sleep, and suicide risk. Multiple machine learning algorithms were tested to determine the best fit. RESULTS: K-nearest neighbors (KNN; k=2) with uniform weighting and the Euclidean distance metric emerged as the most promising algorithm, with 68% mean accuracy (averaged over 10,000 simulations of splitting the training and testing data via 10-fold cross-validation) and an average area under the curve of 0.65. We applied a combined 5×2 F test to test the model performance of KNN against the baseline classifier that guesses training majority, random forest, support vector machine and logistic regression, and achieved F statistics of 10.7 (P=.009) and 17.6 (P=.003) for training majority and random forest, respectively, rejecting the null of performance being the same. Therefore, we have taken the first steps in prototyping a system that could continuously and accurately assess the risk of suicide via mobile devices. CONCLUSIONS: Predicting for suicidality is an underaddressed area of research to which this paper makes a useful contribution. This is part of the first generation of studies to suggest that it is feasible to utilize smartphone-generated user input and passive sensor data to generate a risk algorithm among inpatients at suicide risk. The model reveals fair concordance between phone-derived and research-generated clinical data, and with iterative development, it has the potential for accurate discriminant risk prediction. However, although full automation and independence of clinical judgment or input would be a worthy development for those individuals who are less likely to access specialist mental health services, and for providing a timely response in a crisis situation, the ethical and legal implications of such advances in the field of psychiatry need to be acknowledged.