"It means so much for me to have a choice": a qualitative study providing first-person perspectives on medication-free treatment in mental health care

"Choosing your Own Path": Patterns of Use of Psychiatric Medication among Individuals with Serious Mental Illness

Most individuals with serious mental illness (SMI) are advised to take psychiatric medication, but about half of them do not take it as prescribed. The binary concepts of "adherence" and "non-adherence" do not seem to capture the actual patterns of medication use. The current study mapped the different patterns of medication use among people with SMI and explored the characteristics of each pattern. Sixteen participants diagnosed with an SMI that used psychiatric medications for at least one year, were interviewed, and data were analyzed using ideal-type analysis. Analysis revealed four patterns of medication use: (1) adherence without doubt; (2) adherence after attempts to stop/reduce; (3) flexible use over time; and (4) tapering off medication. Individuals may shift between these different patterns in their recovery journey, creating the need for tailored therapeutic interventions that adapt to individuals' evolving needs, beliefs, and preferences.

[Therapeutic mediation and the alleviation of psychiatric symptoms, a retrospective survey]

The benefits of therapeutic mediations are poorly documented. A retrospective survey showed that they frequently alleviated anxiety, violence and apathy, but significantly less often suicidal and delusional ideation. These symptoms were less of an obstacle to the use of mediation when the professionals involved were nurses and care assistants. Prescribing mediation appears useful.

Autoethnographic Reflections on Mental Distress and Medication Management: Conceptualising Biomedical and Recovery Models of Mental Health

This article uses autoethnography to explore the author's lived experiences of mental distress and how she has conceptualised and explained these symptoms to herself using both the biomedical and recovery models of care. Autoethnography is a process of personal reflection that enables connection between the personal and the political. Experiences of mental distress are recounted alongside the decision to reduce medication. This personal experience is then explored in the context of limited evidence base on the effectiveness of reducing medication and the situation in which prescribers often feel reluctant to recommend and support service users in these choices. Shared decision-making in medication management is introduced which is an approach which draws on the models of recovery and co-production challenging traditional biomedical approaches which locate the prescriber as expert. Moreover, the radical service user led model is highlighted, within which, the Hearing Voices Network and Open Dialogue offer alternative approaches which promote co-production and empowerment. The author connects the personal to the political and reflects on her dual identity as an expert-by-experience and social work academic. She details how she has drawn on biomedical explanations to describe her distress yet has been challenged by the recovery model throughout her journey of recovery. She concludes that her own position, in identifying herself as an academic and expert-by-experience is an important step in challenging notions of expertise and approaches to mental health care.

What is it all about? An explorative study of patients' experiences with medication free treatment

BACKGROUND

As a response to the political decision by the Norwegian Ministry of Health and Care Services to establish some kind of "medication free treatment" for patients with severe mental illness throughout the country, a 6-bed ward unit dedicated to offer such treatment was in 2017 established in Tromsø, Norway by the North Norway Health Care Region. The aim of the present study was to explore the experiences of patients admitted to this ward unit.

METHOD

Semi-structured interviews were conducted with 19 persons who had received treatment from the ward during the period January 2017 to October 2021. Analysis was done in line with Systematic Text Condensation and interviews were recorded, transcribed and analyzed using software NVivo.

RESULTS

The importance of engaging in a dialogue about the possibilities of living a life without medication was unanimously validated, along with a focus on empowerment, motivation, activity and flexibility. Not everyone reported fulfillment of their own wishes or the ward's goal of tapering down, and reflected upon emotions such as ambivalence or fear. Three core concepts were identified to describe the participants' experiences: 1) Tapering off, 2) Relations, and 3) Frames and content. A fourth concept overarches the process formed by these concepts; 4) Processes across categories.

CONCLUSION

The study contributes to a deeper understanding of what "medication free" truly means, going beyond simply taking or not taking medications. It adds nuance to the debate surrounding medication free treatment. The ability to taper off medications is linked to intrapersonal factors, such as readiness and personal commitment, as well as the therapeutic environment, including the frames and values present on the ward. "Medication free" is more complex than it may initially appear, as many participants continue to use some form of psychotropic drugs. The sense of being part of something new and "exclusive" can be understood in light of what participants felt was lacking in previous treatment. It appears to be a need of rediscovering the significance of empowerment and empathic relationships in treatment of severe mental illness, in order to foster a sense of coherence and meaning.

Why do patients want medication free treatment for psychosis? An explorative study on reasons for applying to medication free programs

BACKGROUND

A focus on patient's and service user's perspectives regarding long-term antipsychotic treatment led to a declaration from the Norwegian Ministry of Health in 2015 to offer treatment without psychotropic medication in mental health as a voluntary option in all four health care regions. In the northernmost region, a 6-bed inpatient ward unit was established, uniquely designed to give people with severe mental illness the possibility to choose such treatment. Only voluntary admissions were accepted. The aim of the present study was to explore the motivation for applying for medication free treatment among patients with several years of treatment history due to psychosis.

METHOD

We performed nineteen semi-structured, in-depth interviews with persons having at least one admission at the medication free treatment ward during the period 01.01.17 - 17.10.2021. The interviews were recorded, transcribed and analysed using computer-assisted qualitative data analysis software (NVivo). Systematic Text Condensation was applied, with analysis of data from the first interview. Exploration of connections, similarities and nuances was performed through axial coding with continuous comparison of data and memo writing, followed by focused coding identifying core concepts.

RESULTS

All participants had a diagnosis of severe mental illness and a history of use of antipsychotics throughout many years. The motivation to apply for medication free treatment was complex. Negative experiences with medication were described, but also positive. Many had tried to taper off before, but described this as a lonely and difficult process. Five core concepts were formed and developed from the participants' narratives: 1) Medication experiences, 2) Developing illness, 3) Treatment in general, 4) Social life and 4) Growing up.

CONCLUSION

The concept of medication free treatment represents a salutogenetic hope for change, closely linked to self-efficacy and an experience of mastery. Potential conflicts concerning guidelines or evidence on medication does not come forward as important. Support from family and professionals is crucial, in contrast to the feeling of being alone when hoping for change. Motivational factors are closely linked to the concept of recovery, where interaction happens on both an individual and a structural level.

Perceptions of nurses working in mental health services regarding the recovery-oriented care approach: Findings from Africa

BACKGROUND

The recovery-oriented care approach in mental health is recognised as the vision for mental health. People with a diagnosis of mental illness value the support and the individualistic approach emphasised in the recovery-oriented mental health care approach as they believe it facilitates their recovery. However, as a developing country, Botswana has a long way to go in availing mental health care resources to people with mental illness, let alone adopting new mental health approaches such as recovery.

AIM

The study aimed to explore the perceptions of nurses working in mental health care facilities of recovery-oriented mental health care.

METHODS

Four mental health facilities from Botswana consented to participate in the study. A descriptive qualitative approach was utilised to explore nurses' views on how they perceive recovery from mental illness. Thirty nurses participated in the focus group discussions across the four study sites. All participants consented to participate and to be recorded. Tesch's (in Qualitative enquiry and research design: Choosing among five approaches. 3th ed. SAGE, 2013:198) thematic analysis was used for this study.

RESULTS

Three main themes were identified in participants' perceptions of recovery-oriented care mental health: Recovery from mental illness is possible, the Meaning of recovery from mental illness and Factors facilitating recovery from mental illness.

PUBLIC CONTRIBUTION

The study offers a perspective into how nurses perceive recovery-oriented approaches from a developing country and add to the gap existing in recovery-oriented mental health care approach from the African context.

Medication-free mental health treatment: a focus group study of milieu therapeutic settings

BACKGROUND

Medication-free treatment within mental health care aims to offer therapeutic support as an alternative to psychotropic medication. Introducing milieu therapy for severely mentally ill persons in a medication-free unit requires significant changes to the traditional medication-based psychiatric setting. The present study examines how milieu therapists experience working with medication-free treatment for people with severe mental health challenges. The research question was "What may be required to succeed with medication-free treatment in milieu therapeutic settings?"

METHODS

A qualitative study with four focus groups were conducted with 23 milieu therapists from three inpatient units in two mental health institutions. Thematic analysis was performed.

RESULTS

One main theme was identified: medication-free treatment involves therapists and patients working together on holistic and personal health promotion. This common thread links the four themes: helping patients to make changes in their life; having time to focus on the individual patient; being a professional companion; and working together as a team with the patient.

CONCLUSIONS

A holistic approach is necessary for medication-free treatment to succeed. This requires working together in multidisciplinary teams with a focus on the individual patient. Milieu therapists must engage and take more responsibility in the patient's process of health promotion. A change from a medical to a humanistic paradigm within mental health care is needed.

Nurses' Perceptions on How Recovery-Oriented Mental Health Care Can Be Developed and Implemented

Aim

This study explored how nurses working in inpatient mental health units perceived the development and implementation of a recovery-oriented mental healthcare programme (ROMHCP).

Background

The recovery-oriented mental healthcare approach (ROMHCA) in mental health is regarded as the future of mental health services and has been implemented in different countries worldwide. However, regarding developing and implementing the recovery approach, Africa appears to have been left behind by the rest of the continents.

Design

The study used a qualitative approach to describe how a recovery-oriented mental healthcare approach could be developed.

Methods

Thirty nurses who worked in Botswana's four inpatient mental health facilities consented and voluntarily participated in the study. Data were collected from February to mid-March 2022 through online focus group discussions and analysed using thematic analysis. The COREQ checklist was used to report the findings.

Results

Two main themes emerged as follows: (i) developing and implementing a recovery-oriented mental healthcare programme is possible and (ii) certain elements are required to develop and implement ROMHCP.

Conclusion

The participants believed that people diagnosed with mental illness could recover from the illness and suggested how it could be achieved. They also contended that the programme's success would lie mainly with multisectoral support from policymakers, facilities, hospital personnel, patients, and the community. Clinical Relevance. ROMHCP has the potential to benefit people with mental illness in the country. In addition, it would allow nurses to improve their knowledge and skills in managing mental illnesses. Patient or Public Contribution. The patients and the general public did not contribute to the study's concept, design, and outcomes. However, the nurses working in mental health facilities volunteered to participate in the study.

"Stabilise-reduce, stabilise-reduce": A survey of the common practices of deprescribing services and recommendations for future services

BACKGROUND

Public Health England recently called for the establishment of services to help people to safely stop prescribed drugs associated with dependence and withdrawal, including benzodiazepines, z-drugs, antidepressants, gabapentinoids and opioids. NICE identified a lack of knowledge about the best model for such service delivery. Therefore, we performed a global survey of existing deprescribing services to identify common practices and inform service development.

METHODS

We identified existing deprescribing services and interviewed key personnel in these services using an interview co-produced with researchers with lived experience of withdrawal. We summarised the common practices of the services and analysed the interviews using a rapid form of qualitative framework analysis.

RESULTS

Thirteen deprescribing services were included (8 UK, 5 from other countries). The common practices in the services were: gradual tapering of medications often over more than a year, and reductions made in a broadly hyperbolic manner (smaller reductions as total dose became lower). Reductions were individualised so that withdrawal symptoms remained tolerable, with the patient leading this decision-making in most services. Support and reassurance were provided throughout the process, sometimes by means of telephone support lines. Psychosocial support for the management of underlying conditions (e.g. CBT, counselling) were provided by the service or through referral. Lived experience was often embedded in services through founders, hiring criteria, peer support and sources of information to guide tapering.

CONCLUSION

We found many common practices across existing deprescribing services around the world. We suggest that these ingredients are included in commissioning guidance of future services and suggest directions for further research to clarify best practice.

The Safety and Efficacy of Psychosocial Adherence Interventions in Young People with Early Psychosis: A Systematic Review

Background: The role of antipsychotic medication in supporting young people in their recovery from early psychosis is complex and controversial. It is common for young people, often given antipsychotic medication for the first time, to express a choice to stop treatment, potentially increasing the risk of relapse and admission to hospital. Our systematic review aimed to evaluate the safety and effectiveness of psychosocial interventions to enhance antipsychotic medication adherence in young people with early psychosis. Methods: We reviewed studies using any experimental design of psychosocial interventions specifically focused on enhancing adherence with antipsychotic medication in young people with early psychosis. Cochrane CENTRAL Register, Medline, Embase, PsychINFO and CINAHL were searched on 19 November 2021 without time restriction. Studies were assessed for quality using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results: Our initial search identified 3469 documents. Following title, abstract and full-text screening, we included three published studies and one unpublished experimental study that met our inclusion criteria. Outcome data were available for three studies that tested adherence–coping–education, adherence therapy, and a health dialogue intervention, all having a positive effect on medication adherence. None of the trials reported data on the safety of the experimental interventions. Conclusion: There is a paucity of evidence from high-quality randomized controlled trials that establish the safety and effectiveness of any type of psychosocial intervention to enhance medication adherence in young people with early psychosis. Further high-quality trials are warranted. This review was registered on the Open Science Framework prior to undertaking out initial searches.

What Matters for Evaluating the Quality of Mental Healthcare? Identifying Important Aspects in Qualitative Focus Groups with Service Users and Frontline Mental Health Professionals

Background

Evaluating quality in mental healthcare is essential for ensuring a high-quality experience for service users (SUs). Policy-defined quality indicators, however, risk misalignment with the perspectives of SUs and mental healthcare professionals (MHPs). There is value in exploring how SUs and frontline MHPs think quality should be measured.

Objectives

Our study objectives were to: (1) identify aspects that SUs and MHPs deem important for assessing quality in mental healthcare to help support attribute selection in a subsequent discrete choice experiment and (2) explore similarities and differences between SU and MHPs’ views.

Methods

Semi-structured qualitative focus groups (n = 6) were conducted with SUs (n = 14) and MHPs (n = 8) recruited from a UK National Health Service Trust. A topic guide was generated from a review of UK policy documents and existing data used to measure quality in mental healthcare in England. Transcripts were analysed using a framework analysis.

Results

Twenty-one subthemes were identified, grouped within six themes: accessing mental healthcare; assessing the benefits of care; co-ordinated approach; delivering mental healthcare; individualised care; and role of the person providing care. Themes such as person-centred care, capacity and resources, and receiving the right type of care received more coverage than others. Service users and MHPs displayed high concordance in their views, with minor areas of divergence.

Conclusions

We developed a comprehensive six-theme framework for understanding quality in mental healthcare from the viewpoint of the SU and frontline MHP, which can be used to help inform the selection of a meaningful set of quality indicators in mental health for research and practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00580-0.

How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background

Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment.

Methods

We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation.

Findings

Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening.

Conclusions

Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work.

Trial registration: N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00529-8.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Why Service Users Choose Medication-Free Psychiatric Treatment: A Mixed-Method Study of User Accounts

PURPOSE

Medication has been a central part of treatment for severe mental disorders in Western medicine since the 1950s. In 2015, Norwegian Health Authorities decided that Norwegian health regions must have treatment units devoted to medication-free mental health treatment to enhance service users' freedom of choice. The need for these units has been controversial. The aim of this study was to examine why service users choose medication-free services. This article examines what purpose these units serve in terms of the users' reasons for choosing this service, what is important for them to receive during the treatment, and what factors lay behind their concerns in terms of medication-related views and experiences.

METHODS

Questionnaires were answered by 46 participants and 5 participants were interviewed in a mixed-method design integrated with a concurrent triangulation strategy applying thematic analysis and descriptive statistics.

RESULTS

Negative effects of medications and unavailable alternatives to medication in ordinary health care were important reasons for wanting medication-free treatment. Medication use may conflict with personal values, attitudes, and beliefs.

CONCLUSION

This study broadens the understanding of why the demand for separate medication-free units has arisen. The findings may contribute to making medication-free treatment an option in mental health care in general. To this end, clinicians are advised to communicate all treatment alternatives to service users and to be mindful of the effect of power imbalances in their interactions with them.

Service-user efforts to maintain their wellbeing during and after successful withdrawal from antipsychotic medication

BACKGROUND

It is well-known that attempting antipsychotic withdrawal can be a fraught process, with a high risk of relapse that often leads people to resume the medication. Nonetheless, there is a group of people who appear to be able to discontinue successfully. Relatively little is known about how people do this.

METHODS

A convenience sample of adults who had stopped taking antipsychotic medication for more than a year were recruited to participate in semi-structured interviews through an anonymous online survey that investigated antipsychotic medication experiences in New Zealand. Thematic analysis explored participant descriptions of their efforts to maintain their wellbeing during and after the withdrawal process.

RESULTS

Of the seven women who volunteered to participate, six reported bipolar disorder diagnoses and one reported diagnoses of obsessive compulsive disorder and depression. The women reported successfully discontinuing antipsychotics for 1.25-25 years; six followed a gradual withdrawal method and had support to prepare for and manage this. Participants defined wellbeing in terms of their ability to manage the impact of any difficulties faced rather than their ability to prevent them entirely, and saw this as something that evolved over time. They described managing the process and maintaining their wellbeing afterwards by 'understanding myself and my needs', 'finding what works for me' and 'connecting with support'. Sub-themes expand on the way in which they did this. For example, 'finding what works for me' included using a tool-box of strategies to flexibly meet their needs, practicing acceptance, drawing on persistence and curiosity and creating positive life experiences.

CONCLUSION

This is a small, qualitative study and results should be interpreted with caution. This sample shows it is possible for people who experience mania and psychosis to successfully discontinue antipsychotics and safely manage the impact of any symptoms that emerge as a result of the withdrawal process or other life stressors that arise afterwards. Findings suggest internal resources and systemic factors play a role in the outcomes observed among people who attempt to stop taking antipsychotics and a preoccupation with avoiding relapse may be counterproductive to these efforts. Professionals can play a valuable role in facilitating change.