The Help-Seeking Experiences of Parents of Children with a First-Episode of Psychosis

Structural barriers to help-seeking in first-episode psychosis: A systematic review and thematic synthesis

AIM

Access to timely treatment is key to early intervention in psychosis. Despite this, barriers to treatment exist. In this review, we aimed to understand the structural barriers that patients and caregivers face in help-seeking for first-episode psychosis, and the recommendations provided to address these.

METHODS

We conducted a systematic review (PROSPERO: CRD42021274609) of qualitative studies reporting structural barriers to help-seeking from the patient or caregiver perspective. Searches were performed in September 2023, restricted to studies published from 2001. Study quality was appraised using Critical Appraisal Skills Programme. Data were analysed using thematic synthesis.

RESULTS

Nineteen papers from 11 countries were included. Across all papers, participants reported experiencing structural barriers to receiving healthcare. For many patients and caregivers, the process of accessing healthcare is complex. Access requires knowledge and resources from parents, caregivers and healthcare providers, yet too often there is a misalignment between patients' needs and service resources. Expertise amongst healthcare providers vary and some patients and caregivers experience negative encounters in healthcare. Patients highlighted earlier caregiver involvement and greater peer support as potential routes for improvement.

CONCLUSION

Patients and caregivers face multiple structural barriers, with legislative practices that discourage family involvement, and healthcare and transport costs found to be particularly problematic. Understanding these barriers can facilitate the co-design of both new and existing services to provide easier access for patients and caregivers. Further research is needed focusing not only on the perspectives of patients and caregivers who have accessed professional help but also crucially on those who have not.

User-Centered Development of Bolster, an mHealth Intervention for Early Psychosis Caregivers: Needs Assessment, Prototyping, and Field Trial

BACKGROUND

Caregivers play a critical role in the treatment and recovery of youth and young adults at risk for psychosis. Caregivers often report feeling isolated, overwhelmed, and lacking in resources. Mobile health (mHealth) has the potential to provide scalable, accessible, and in-the-moment support to caregivers. To date, few if any mHealth resources have been developed specifically for this population.

OBJECTIVE

The aim of this study was to conduct user-centered design and testing of an mHealth intervention to support early psychosis caregivers.

METHODS

We conducted a multiphase user-centered development process to develop the Bolster mobile app. In phase 1, a total of 21 caregivers were recruited to participate in a qualitative needs assessment and respond to an initial prototype of the Bolster platform. Content analysis was used to identify key needs and design objectives, which guided the development of the Bolster mobile app. In phase 2, a total of 11 caregivers were recruited to participate in a 1-week field trial wherein they provided qualitative and quantitative feedback regarding the usability and acceptability of Bolster; in addition, they provided baseline and posttest assessments of the measures of distress, illness appraisals, and family communication.

RESULTS

In phase 1, participants identified psychoeducation, communication coaching, a guide to seeking services, and support for coping as areas to address. Live prototype interaction sessions led to multiple design objectives, including ensuring that messages from the platform were actionable and tailored to the caregiver experience, delivering messages in multiple modalities (eg, video and text), and eliminating a messaging-style interface. These conclusions were used to develop the final version of Bolster tested in the field trial. In phase 2, of the 11 caregivers, 10 (91%) reported that they would use Bolster if they had access to it and would recommend it to another caregiver. They also reported marked changes in their appraisals of illness (Cohen d=0.55-0.68), distress (Cohen d=1.77), and expressed emotion (Cohen d=0.52).

CONCLUSIONS

To our knowledge, this study is the first to design an mHealth intervention specifically for early psychosis caregivers. Preliminary data suggest that Bolster is usable, acceptable, and promising to improve key targets and outcomes. A future fully powered clinical trial will help determine whether mHealth can reduce caregiver burdens and increase engagement in services among individuals affected by psychosis.

A Qualitative Exploration of Ontario Caregivers' Perspectives of Their Role in Navigating Mental Health and/or Addiction Services for Their Youth

Many youth experiencing mental health and/or addiction (MHA) concerns rely on their caregivers to find and access services. Considering that caregivers often play a significant role in their youth's treatment trajectory, a descriptive qualitative study was used to explore how caregivers (n = 26) in the Greater Toronto Area perceive their role in navigating MHA care for their youth (ages 13 to 26). The Person-Environment-Occupation model was used to guide the thematic analysis. The findings reveal three main themes (1) the internal experience of caregiving, which describes caregivers' emotions and thought processes; (2) the external factors impacting the caregiver's ability to find and access youth MHA services, which explores systemic and social factors that impact navigation; and (3) the demands of the caregiving role. The discussion highlights the importance of supporting the wellbeing of caregivers as they navigate youth MHA services and can provide useful information for healthcare professionals and policy-makers to increase equitable access to youth MHA services.

Feasibility of Text Messages for Enhancing Therapeutic Engagement Among Youth and Caregivers Initiating Outpatient Mental Health Treatment: Mixed Methods Study

BACKGROUND

Pathways to mental health services for youth are generally complex and often involve numerous contact points and lengthy delays. When starting treatment, there are a host of barriers that contribute to low rates of therapeutic engagement. Automated text messages offer a convenient, low-cost option for information sharing and skill building, and they can potentially activate positive behaviors in youth and caregivers prior to beginning formal therapy. To date, there is little evidence for the feasibility of initiating transdiagnostic text messages during the early stages of youth and caregiver contact with community outpatient mental health services.

OBJECTIVE

To develop and test the feasibility of implementing 2 novel text messaging campaigns aimed at youth clients and their caregivers during the early stages of engaging with outpatient mental health services.

METHODS

A multidisciplinary panel of experts developed two 12-message interventions with youth and caregivers prior to deployment. Each message included a link to an external interactive or multimedia resource to extend skill development. Enrollment of youth aged 13 to 18 years, their caregivers, or both occurred at 2 early treatment timepoints. At both time points, text messages were delivered automatically 2 times a week for 6 weeks. Analytics and survey data were collected in 2 phases, between January and March 2020 and between January and May 2021. Enrollment, willingness to persist in using the intervention, engagement, satisfaction, perceived value, and impact were measured. Descriptive statistics were used to summarize youth and caregiver outcomes.

RESULTS

A total of 41 caregivers and 36 youth consented to participate. Follow-up survey response rates were 54% (22/41) and 44%, (16/36) respectively. Over 1500 text messages were sent throughout the study. More than three-quarters (14/16, 88%) of youth reported that they learned something new and noticed a change in themselves due to receiving the texts; the same proportion (14/16, 88%) of youth said they would recommend the text messages to others. Youth ranked the first text message, related to coping with difficult emotions, as the most helpful of the series. Caregivers reported acting differently due to receiving the texts. Over two-thirds of caregivers were satisfied with the texts (16/22, 73%) and would recommend them to others (16/22, 73%). Caregivers perceived diverse levels of value in the text topics, with 9 of the 12 caregiver texts rated by at least one caregiver as the most helpful.

CONCLUSIONS

Results are preliminary but show that brief, core skill-focused text messages for youth clients and caregivers in community outpatient mental health services are feasible. Both youth and caregivers reported promising knowledge and behavior change with exposure to only 12 messages over 6 weeks. A larger study with statistical power to detect changes in both perceived helpfulness and engagement is required to confirm the effectiveness of this type of transdiagnostic intervention.

Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review

Worldwide, growing concern with young people's mental health is spurring service reform efforts. Such reform requires a full understanding of the experiences of young people and their carers when seeking mental health help. To generate such an understanding, we conducted a meta-synthesis of qualitative literature on the perspectives of youths and their carers on navigating mental health systems. Five electronic databases were searched (Medline, PsycINFO, EMBASE, CINAHL, HealthSTAR). Studies were included if they explored the experiences of pathways to mental health services of persons aged 11-30 years and/or their carers; were published in English or French; and used qualitative methodology. Quality appraisal was conducted using the CASP tool. The synthesis of 31 included studies yielded three themes-initiating contact with mental health services; characteristics of services' response; and youths' and carers' appraisal of services. Themes about initiating contact included mental health literacy, structural barriers, and social support. Service response-related themes included complex pathways, waitlists, eligibility, and fragmented care. In terms of service appraisal, positive encounters featured providers who were accessible and perceived as caring. Negative appraisals resulted from feeling misunderstood and excluded and being ill-informed about treatment. Across diagnoses and settings, youths and carers had difficult experiences accessing mental healthcare. While individual, social, and healthcare factors shaping pathways to care varied, systemic complexities were a common inhibitor. This synthesis informs recommendations for improving mental health services and youths' pathways to them. It underlines the need for grounding reform in youths' and carers' perspectives and needs.

Parents' Experiences of Caring for Their Only Child With Mental Illness in China: A Qualitative Study

The current study explored Chinese parents' experiences of caring for their only child with mental illness. Face-to-face interviews with semi-structured questions were conducted to learn about the care experiences of parents whose only child had mental illness. Purposeful sampling was used to recruit parents (n = 14) and thematic analysis was used. Five themes were identified: (1) Having Responsibility to Care for Children, (2) Feeling Guilt and Self-Blame, (3) Experiencing Loneliness and Helplessness, (4) Drained by Caregiving, and (5) Worrying About the Future. Parents who cared for their only child with mental illness experienced considerable emotional and physical challenges. Professionals and health care providers should recognize and understand the experiences of these parents to identity their needs and provide adequate support. Targeted support services and appropriate professional information should be developed and provided for parents to relieve them of negative caregiving experiences and improve their psychological and physical well-being. [Journal of Psychosocial Nursing and Mental Health Services, 59(1), 29-37.].

Family Experiences Prior to the Initiation of Care for First-Episode Psychosis: A Meta-Synthesis of Qualitative Studies

OBJECTIVES

This study systematically reviewed existing qualitative evidence of family members' experiences prior to the initiation of mental health services for a loved one experiencing their first episode of psychosis (FEP).

METHODS

A meta-synthesis review of published peer-reviewed qualitative studies conducted between 2010 and 2019 were included. Keyword searches were performed in four electronic databases and the reference lists of primary manuscripts. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess methodological quality of each study.

RESULTS

A total of 365 articles were initially identified and 9 were articles identified in a secondary review and literature search. A total of 21 met inclusion criteria. Of those included in this review 169, mothers were the primary family to recall experiences. The meta-synthesis identified four major themes related to family member experiences prior to the initiation of mental health services for FEP: the misinterpretation of signs, the emotional impact of FEP on family members, the effect of stigma on family members, and engaging with resources prior to mental health services for FEP.

CONCLUSIONS

Additional research is needed to develop healthy communication strategies that effectively deliver educational information about psychosis. This meta-synthesis also identified the need to understand help-seeking behaviors among families of those with FEP in effort to reduce the duration of untreated psychosis and improve pathways to care often initiated by a family member.

Understanding Individual and Family Experiences Associated with DUP: Lessons from the Early Assessment and Support Alliance (EASA) Program in Oregon, USA

Research shows that a longer duration of untreated psychosis (DUP) is associated with worse psychiatric outcomes, with average length of DUP of 73 weeks in the U.S. The aim was to examine the DUP period for first episode psychosis in Oregon, with a focus on the processes between the first positive symptoms and first treatment. To investigate DUP, researchers used methods consistent with grounded theory to collect data from 9 participants and their families about the process between onset of psychotic symptoms and entrance into treatment. Results suggest that recognition of symptoms was the primary driver of help-seeking in this study, and this was influenced by type of symptom as well as the presence or absence of supportive others, which in most cases was regular family contact. Implications indicate a need for in-depth research on individual and family recognition of symptoms, as well as underscoring the need for community education.

Where to seek help? Barriers to beginning treatment during the first-episode psychosis

Objective

As decreasing the duration of untreated psychosis has been highlighted as key indicator in relation to improved prognosis, this study aims to identify the access barriers to beginning early treatment of young people in first-episode psychosis (FEP), based on family reports on the experience of perceiving illness and help-seeking.

Method

A qualitative research was carried out with 12 relatives of 12 young people passing through their first psychiatric hospital admission as a result of their FEP. Depth interviews were used for data collection and thematic content method for data analysis.

Results

Barriers to beginning treatment were lack of knowledge and difficulty in recognizing mental illness, lack of knowledge on where to seek specialized treatment, and stigma and resistance to psychiatric treatment.

Conclusion

It was demonstrated that the family members are protagonists in the search for treatment of young people in their FPE, given that the initiative for seeking treatment came from them.

Understanding Pathways to Care of Individuals Entering a Specialized Early Intervention Service for First-Episode Psychosis

OBJECTIVE

This study aimed to understand the pathways to care from the onset of a first episode of psychosis to entry into a specialized early intervention service (EIS) for individuals with nonaffective psychosis.

METHODS

A sample of 20 individuals who participated in an EIS and ten of their family members were enrolled. Semistructured qualitative interviews were used to characterize participants' lives during the onset of psychosis and explore their help-seeking events from the onset of psychosis to entry into the EIS. Data were analyzed by using grounded theory and a case study methodology.

RESULTS

The median duration between the onset of psychosis and EIS entry was 4.5 months. A grounded model emerged from the analysis that captured how help-seeking decisions were influenced by the misattribution of symptoms, stigma, and self-reliance. These factors created a cloud of uncertainty in which individuals experiencing early psychosis and their family members struggled to make sense of what was happening, how and when to seek help, and what to expect from treatment. Contacts with the health care system were critical junctures in the pathway to care that could reduce or increase uncertainty and expedite or delay EIS entry.

CONCLUSIONS

Findings indicate that efforts to expedite EIS entry should focus on reducing the uncertainty that affected individuals and their family members face when seeking care by improving their experiences with mental health services.

The Common Elements of treatment engagement for clinically high-risk youth and youth with first-episode psychosis

AIM

Without treatment, clinically high-risk (CHR) youth or youth with first-episode psychosis (FEP) have increased risk for significant complications from their illness; yet, treatment engagement among these youth is critically low. The purpose of this study was to examine engagement efforts with CHR/FEP youth to stimulate new ideas that might facilitate participation in services for this population.

METHODS

A literature review using distillation methods identified engagement practices reported in two bodies of literature. The first body of literature (i.e. 'CHR/FEP engagement') included 13 studies employing qualitative designs to explore consumer perspectives about treatment engagement practices in samples of CHR/FEP youth and their families. The second body of research (i.e. 'CHR/FEP RCTs') included 18 randomized controlled trials (RCTs) testing treatments for CHR/FEP youth and their families. Engagement practice frequencies were compared with the frequency of these practices within effective engagement interventions, as tested in 40 RCTs within the broader child and adolescent mental health literature (i.e. 'CAMH engagement').

RESULTS

Treatment attrition and attendance were the most frequent engagement outcomes measured in the CHR/FEP RCTs. There were notable efforts described in the CHR/FEP RCTs towards engaging youth and families, yet CHR/FEP RCTs reportedly included only a small proportion of engagement practices described in either the CHR/FEP or CAMH engagement literatures.

CONCLUSION

Results suggest there might be practices available to complement current efforts at engaging CHR/FEP youth in treatment, and that increased attention to the measurement of engagement outcomes could provide important information regarding engagement in a population with low treatment engagement rates.