Clinical effectiveness and cost-effectiveness of Structured Psychological Support for people with probable personality disorder in mental health services in England: study protocol for a randomised controlled trial.

INTRODUCTION: Evidence-based psychological treatments for people with personality disorder usually involve attending group-based sessions over many months. Low-intensity psychological interventions of less than 6 months duration have been developed, but their clinical effectiveness and cost-effectiveness are unclear. METHODS AND ANALYSIS: This is a multicentre, randomised, parallel-group, researcher-masked, superiority trial. Study participants will be aged 18 and over, have probable personality disorder and be treated by mental health staff in seven centres in England. We will exclude people who are: unwilling or unable to provide written informed consent, have a coexisting organic or psychotic mental disorder, or are already receiving psychological treatment for personality disorder or on a waiting list for such treatment. In the intervention group, participants will be offered up to 10 individual sessions of Structured Psychological Support. In the control group, participants will be offered treatment as usual plus a single session of personalised crisis planning. The primary outcome is social functioning measured over 12 months using total score on the Work and Social Adjustment Scale (WSAS). Secondary outcomes include mental health, suicidal behaviour, health-related quality of life, patient-rated global improvement and satisfaction, and resource use and costs. The primary analysis will compare WSAS scores across the 12-month period using a general linear mixed model adjusting for baseline scores, allocation group and study centre on an intention-to-treat basis. In a parallel process evaluation, we will analyse qualitative data from interviews with study participants, clinical staff and researchers to examine mechanisms of impact and contextual factors. ETHICS AND DISSEMINATION: The study complies with the Helsinki Declaration II and is approved by the London-Bromley Research Ethics Committee (IRAS ID 315951). Study findings will be published in an open access peer-reviewed journal; and disseminated at national and international conferences. TRIAL REGISTRATION NUMBER: ISRCTN13918289.

Care giving and receiving for people with complex emotional needs within a crisis resolution/home treatment setting: A qualitative evidence synthesis.

WHAT IS KNOWN ON THE SUBJECT?: The term 'complex emotional needs' (CEN) is used here to describe people with difficulties and needs that are often associated with the diagnostic label of 'personality disorder'. People with CEN might use out of hours services such as emergency departments and Crisis Resolution/Home Treatment (CRHT) teams more often when experiencing a mental health crisis. Very little is understood about the experiences of both those receiving, and those delivering care, for people with CEN within CRHT settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: There are differences between priorities for those delivering and those receiving care within CRHT settings. CRHT staff members are likely to focus more upon those aspects of their role relating to risk issues. managing resources, anxieties and the expectations of others. Service users, meanwhile, focus upon the caring relationship, wanting staff to listen to them, and to feel supported and reassured. In the papers reviewed, service users experiencing CEN did not always feel 'listened to' or 'taken seriously' especially in relation to risk issues and decision-making. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Relating the findings to mental health nursing and CEN within the context of CRHT, to better understand the person experiencing a mental health crisis, mental health nurses need to focus more upon the person and when making decisions around their care and must be aware of the potential for power imbalances. Collaborative 'sense-making' in relation to a person's risk behaviours may help. ABSTRACT: Background A growing body of qualitative evidence focusing upon the experiences of care within Crisis Resolution/Home Treatment (CRHT) is emerging; however, a firm evidence base regarding both the giving and receiving of care for those with complex emotional needs (CEN) in this context is yet to be established. Objective A qualitative evidence synthesis was used to develop a comprehensive understanding of how crisis care for people with CEN is experienced by both those giving and receiving care, within the context of CRHT. Method Findings from 19 research papers considering both clinician and service users' experiential accounts of CRHT were synthesised using meta-ethnography. Findings Both the giving and receiving of care within a CRHT context was experienced across four related meta-themes: 'contextual', 'functional', 'relational' and 'decisional'. Discussion Service user accounts focused upon relational aspects, highlighting a significance to their experience of care. Meanwhile, clinicians focused more upon contextual issues linked to the management of organisational anxieties and resources. For those with CEN, a clinician's focus upon risk alone highlighted power differentials in the caring relationship. Conclusions There is a need for nurses to connect with the experience of the person in crisis, ensuring a better balance between contextual issues and relational working.

Relational practice in health, education, criminal justice, and social care: a scoping review.

BACKGROUND: Establishing and maintaining relationships and ways of connecting and being with others is an important component of health and wellbeing. Harnessing the relational within caring, supportive, educational, or carceral settings as a systems response has been referred to as relational practice. Practitioners, people with lived experience, academics and policy makers, do not yet share a well-defined common understanding of relational practice. Consequently, there is potential for interdisciplinary and interagency miscommunication, as well as the risk of policy and practice being increasingly disconnected. Comprehensive reviews are needed to support the development of a coherent shared understanding of relational practice. METHOD: This study uses a scoping review design providing a scope and synthesis of extant literature relating to relational practice focussing on organisational and systemic practice. The review aimed to map how relational practice is used, defined and understood across health, criminal justice, education and social work, noting any impacts and benefits reported. Searches were conducted on 8 bibliographic databases on 27 October 2021. English language articles were included that involve/discuss practice and/or intervention/s that prioritise interpersonal relationships in service provision, in both external (organisational contexts) and internal (how this is received by workers and service users) aspects. RESULTS: A total of 8010 relevant articles were identified, of which 158 met the eligibility criteria and were included in the synthesis. Most were opinion-based or theoretical argument papers (n = 61, 38.60%), with 6 (3.80%) critical or narrative reviews. A further 27 (17.09%) were categorised as case studies, focussing on explaining relational practice being used in an organisation or a specific intervention and its components, rather than conducting an evaluation or examination of the effectiveness of the service, with only 11 including any empirical data. Of the included empirical studies, 45 were qualitative, 6 were quantitative, and 9 mixed methods studies. There were differences in the use of terminology and definitions of relational practice within and across sectors. CONCLUSION: Although there may be implicit knowledge of what relational practice is the research field lacks coherent and comprehensive models. Despite definitional ambiguities, a number of benefits are attributed to relational practices. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021295958.

Factors Associated with Trust in Public Authorities Among Adults in Norway, United Kingdom, United States, and Australia Two Years after the COVID-19 Outbreak.

Objectives: This study aimed to examine the levels of trust in information provided by public authorities 2 years after the COVID-19 outbreak and to examine factors associated with trust. Methods: Using a cross-national approach, online survey data was collected from four Western countries-Australia, Norway, the United Kingdom, and the United States of America. Differences in reports of very low or low levels of trust were examined by age, gender, area of residence, and the highest level of education in the four countries. Results: Levels of trust in the public authorities' information were highest among Norwegian respondents and lowest among U.K. respondents. Lower levels of trust in public authorities were found among males, individuals living in rural or remote areas, and those with lower levels of education. Conclusion: The outcomes contribute to knowledge regarding differences between socio-demographic groups and countries regarding the levels of trust people have in public authorities' information concerning a crisis, such as COVID-19. Strategies to promote trust in societies in different countries could consider these socio-demographic differences.

Motivation and Hesitancies in Obtaining the COVID-19 Vaccine-A Cross-Sectional Study in Norway, USA, UK, and Australia.

BACKGROUND: Vaccinations protect the public against serious diseases or death; however, some individuals are hesitant in obtaining them. We aim to contribute to the understanding of the challenges of vaccination roll-out by examining the motivations, hesitancies, and their associated factors, in obtaining the COVID-19 vaccines two years into the pandemic. METHODS: Cross-sectional online surveys were conducted in Norway, the USA, the UK, and Australia (N = 1649). The participants self-reported whether they had obtained one of the COVID-19 vaccines. Those who had obtained a vaccine reported the reason for their motivation, and those who had not obtained a vaccine reported the reason for their hesitancies. RESULTS: More than 80% of the total sample obtained a COVID-19 vaccine because of public health recommendations and trusted that it was safe. Among those who had not obtained one, the most frequent reason was concerns about side effects. Most who obtained the vaccine reported that they believed in science, but many of those who had not obtained one reported distrust. Among those who had not obtained a vaccine, reports of distrust in policies and science were frequent. Concerns about side effects were more common in males and those with lower education, and those living in rural or remote areas. CONCLUSION: People who endorsed the vaccine believed that the vaccine reduces the risk of illness, protects the health of others, and had trust in scientific vaccination research. Conversely, the most frequent reason for vaccine hesitancy was concerns about side effects, followed by distrust in healthcare and science. These findings could inform public health strategies that aim to increase vaccination rates.

Perceptions of social media challenges and benefits during the Covid-19 pandemic: Qualitative findings from a cross sectional international survey.

Since the beginning of the Covid-19 pandemic in January 2020 the need for rapid information spread grew and social media became the ultimate platform for information exchange as well as a tool for connection and entertainment. With the rapid information spread along came the various public misconceptions and misinformation which consequently influenced perceptions and behaviors of the public towards the coronavirus pandemic. Thus, there was a need for identification and collation of public perceptions information to address future public health initiatives. This cross-national study aimed to examine the challenges and benefits of using social media during the Covid-19 pandemic outbreak. This study was a content analysis of the open-ended questions from a wider cross-sectional online survey conducted in Norway, UK, USA, and Australia during October/November 2020. 2368 participants out of 3474 respondents to the survey provided the open text responses included in the qualitative analysis. Thematic analysis was conducted independently by two researchers. All statements were coded to positive and negative sentiments. Three overarching themes were identified: 1. Mental health and emotional exhaustion 2. Information and misinformation; 3. Learning and inspiration.While providing a powerful mode of connection during the pandemic, social media also led to negative impact on public perceptions, including mistrust and confusion. Clarity in communications by institutions and education about credible information sources should be considered in the future. Further research is required in exploring and documenting social media narratives around COVID-19 in this and any subsequent incidents of pandemic restrictions. Understanding the public perceptions and their social narratives can support the designing of appropriate support and services for people in the future, while acknowledging the uncertainty and overwhelming impact of the pandemic that may have skewed the experiences of social media.

Associations between social media use and loneliness in a cross-national population: do motives for social media use matter?

BACKGROUND: We aimed to examine the association between social media use and loneliness two years after the COVID-19 pandemic outbreak. METHODS: Participants were 1649 adults who completed a cross-sectional online survey disseminated openly in Norway, United Kingdom, USA, and Australia between November 2021 and January 2022. Linear regressions examined time spent on social media and participants' characteristics on loneliness, and interactions by motives for social media use. RESULTS: Participants who worried more about their health and were younger, not employed, and without a spouse or partner reported higher levels of loneliness compared to their counterparts. More time spent on social media was associated with more loneliness (ß = 0.12, p < 0.001). Three profile groups emerged for social media use motives: 1) social media use motive ratings on avoiding difficult feelings higher or the same as for maintaining contact; 2) slightly higher ratings for maintaining contact; and 3) substantially higher ratings for maintaining contact. Time spent on social media was significant only in motive profile groups 2 and 3 (ß = 0.12 and ß = 0.14, both p < 0.01). CONCLUSIONS: Our findings suggest that people who use social media for the motive of maintaining their relationships feel lonelier than those who spend the same amount of time on social media for other reasons. While social media may facilitate social contact to a degree, they may not facilitate the type of contact sought by those who use social media primarily for this reason.

Self-Reported Long COVID in the General Population: Sociodemographic and Health Correlates in a Cross-National Sample.

We aimed to gain knowledge of possible sociodemographic predictors of long COVID and whether long COVID was associated with health outcomes almost two years after the pandemic outbreak. There were 1649 adults who participated in the study by completing a cross-sectional online survey disseminated openly in Norway, the UK, the USA, and Australia between November 2021 and January 2022. Participants were defined as having long COVID based on self-reports that they had been infected by COVID-19 and were experiencing long-lasting COVID symptoms. Logistic regression analyses were used to examine possible sociodemographic predictors, and multivariate analysis of variance was used to examine whether long COVID status was associated with health outcomes. None of the sociodemographic variables was significantly associated with reporting long COVID. Having long COVID was associated with higher levels of psychological distress, fatigue, and perceived stress. The effect of long COVID on health outcomes was greater among men than among women. In conclusion, long COVID appeared across sociodemographic groups. People with long COVID reported worsened health outcomes compared to those who had had COVID-19 but without long-term symptoms. Men experiencing long COVID appear to be particularly vulnerable to experiencing poorer health outcomes; health services may pay extra attention to potentially unnoticed needs for support among men experiencing long COVID.

The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trial.

Background: Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted. Methods: Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400 mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at 6 months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at 6 months adjusted for baseline score, allocation group and site. Results: The study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at 6 months, of whom 21 (72%) were included in the mITT analysis. At 6 months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at 6 months was -3.86 (95% Confidence Intervals = -10.04 to 2.32). There were 14 serious adverse events; 6 in the clozapine arm and 8 in the placebo arm of the trial. There was little difference in the cost of care between groups. Interpretation: We recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units. Trial registration: ISRCTN18352058. https://doi.org/10.1186/ISRCTN18352058.

Learning the subtle dance: The experience of therapists who deliver mentalisation-based therapy for borderline personality disorder.

OBJECTIVES: This study aimed to understand therapists' lived experiences of delivering mentalisation-based therapy (MBT), including their experiences of service user change. METHOD: One-to-one semi-structured interviews or focus groups were conducted with 14 MBT therapists and analysed using interpretative phenomenological analysis (IPA). RESULTS: Four superordinate themes were identified: (1) experiencing the challenges and complexities of being with service users during MBT; (2) being on a journey of discovery and change; (3) being an MBT therapist: a new way of working and developing a new therapeutic identity; and (4) being a therapist in the group: seeing it all come together. CONCLUSION: Our findings highlight the complexity, challenges and individualised experience of working therapeutically with service users with a diagnosis of BPD. The study provides a perspective of service use change that is enriched by idiosyncrasies within the therapeutic encounter. We conclude with a consideration of implications for MBT research and clinical practice.

Personality disorder co-morbidity in primary care 'Improving Access to Psychological Therapy' (IAPT) services: a qualitative study exploring patient perspectives on treatment experience.

BACKGROUND: High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care 'Improving Access to Psychological Therapies' (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England. AIMS: This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the 'Standardised Assessment of Personality - Abbreviated Scale' (SAPAS) in receipt of primary care-based IAPT treatment. METHOD: A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach. RESULTS: Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important. CONCLUSIONS: For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.

Psychosocial Support for Healthcare Workers During the COVID-19 Pandemic.

The novel corona virus disease COVID-19 was first diagnosed in humans in Wuhan, China in December 2019. Since then it had become a global pandemic. Such a pandemic leads to short- and long-term mental health burden for healthcare workers. Recent surveys suggest that rates of psychological stress, depression, anxiety, and insomnia and will be high for this group. Numerous organizations have since released guidance on how both healthcare workers and the general public can manage the mental health burden. However, these recommendations focus on specific healthcare workers (e.g., nurses or psychologists), are often not evidence-based, and typically do not situate guidance within a phased model that recognizes countries are at different stages of the COVID-19 pandemic. In this perspective paper we propose a phased model of mental health burden and responses. Building on work by the Intensive Care Society and the Royal College of Psychiatrists in the United Kingdom, we present a model that demonstrates how both staff and organizations might respond to the likely stressors that might occur at preparation-, pre-, initial and core-, and longer-term-phases of the pandemic. Staff within countries at different stages of the COVID-19 pandemic will be able to use this model. We suggest practical tips for both healthcare workers and organizations and embed this within up-to-date scientific literature. The phased model of mental health burden and responses can be a helpful guide for both staff and organizations operating at different stages of the pandemic.

Personality disorder co-morbidity in primary care 'Improving Access to Psychological Therapy' services: A qualitative study exploring professionals' perspectives of working with this patient group.

A high prevalence of people present to 'Improving Access to Psychological Therapies' (IAPT) in England with common mental health disorders and co-morbid personality disorder. This group have suboptimal treatment outcomes in IAPT. Whilst new short-term treatment approaches are advocated, no solutions or guidance have been provided. This qualitative study explored IAPT health-care professional (N = 28) perspectives of working with people who present to IAPT with co-morbid personality disorder. Individual semi-structured interviews were digitally recorded, transcribed verbatim and analysed using a framework analysis approach. Results identified a lack of skills and confidence in working with this patient group, restrictive service constraints and a treatment gap between the interface of primary and secondary services. Insight into acceptable adaptions to practice are identified that have transferable utility to a wider international audience who can identify people outside of specialist mental health services with common mental health disorders and co-morbid personality disorder traits. © 2019 John Wiley & Sons, Ltd.

An inclusive approach to personality disorders.

Personality disorder is one of the most misunderstood of mental health disorders. Historically, people with this diagnosis have experienced exclusion and rejection from mainstream mental health services and wider multi-agency services. This article describes the development of a new strategy to build strong, seamless links across multi-agency services with the aim of providing timely interventions, improving patient experience and reducing the likelihood of transitions to more costly services.

Raising awareness of borderline personality disorder and self-injury.

People with personality disorders frequently present to general health services. A large proportion of people with borderline personality disorder will self-injure and seek physical clinical interventions from adult or practice nurses. These patients are often excluded from services and are highly stigmatised both in mental health services and the wider society. This article aims to increase the awareness of borderline personality disorder and self-injury among non-mental health nurses to assist them to work more effectively with patients who present with these difficulties.

Early psychosis: raising awareness among non-mental health nurses.

People developing psychosis often seek help several times before receiving effective support and treatment, and frequently present to general healthcare staff. Therefore, awareness and knowledge of early psychosis among non-mental health nurses should be promoted. This article aims to provide an overview of psychosis, including signs and symptoms of the condition. Nurses need to be able to direct people displaying signs of early psychosis to the most appropriate services for timely assessment, support and treatment.