Understanding the Impacts of Online Mental Health Peer Support Forums: Realist Synthesis

BACKGROUND

Online forums are widely used for mental health peer support. However, evidence of their safety and effectiveness is mixed. Further research focused on articulating the contexts in which positive and negative impacts emerge from forum use is required to inform innovations in implementation.

OBJECTIVE

This study aimed to develop a realist program theory to explain the impacts of online mental health peer support forums on users.

METHODS

We conducted a realist synthesis of literature published between 2019 and 2023 and 18 stakeholder interviews with forum staff.

RESULTS

Synthesis of 102 evidence sources and 18 interviews produced an overarching program theory comprising 22 context-mechanism-outcome configurations. Findings indicate that users' perceptions of psychological safety and the personal relevance of forum content are foundational to ongoing engagement. Safe and active forums that provide convenient access to information and advice can lead to improvements in mental health self-efficacy. Within the context of welcoming and nonjudgmental communities, users may benefit from the opportunity to explore personal difficulties with peers, experience reduced isolation and normalization of mental health experiences, and engage in mutual encouragement. The program theory highlights the vital role of moderators in creating facilitative online spaces, stimulating community engagement, and limiting access to distressing content. A key challenge for organizations that host mental health forums lies in balancing forum openness and anonymity with the need to enforce rules, such as restrictions on what users can discuss, to promote community safety.

CONCLUSIONS

This is the first realist synthesis of online mental health peer support forums. The novel program theory highlights how successful implementation depends on establishing protocols for enhancing safety and strategies for maintaining user engagement to promote forum sustainability.

TRIAL REGISTRATION

PROSPERO CRD42022352528; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=352528.

Patterns of resilient functioning in early life: Identifying distinct groups and associated factors

Resilience, the capacity to maintain or regain functionality in the face of adversity, is a dynamic process influenced by individual, familial, and community factors. Despite its variability, distinct resilience trajectories can be identified within populations, yet the predictors defining these distinct groups remains largely unclear. Here, using data from the Avon Longitudinal Study of Parents and Children (ages 0-18), we quantify resilience as the remaining variance in psychosocial functioning after taking into account the exposure to adversity. Growth mixture modeling identified seven distinct resilience trajectories, with over half of the study population maintaining resilience throughout early life. Factors increasing the likelihood of resilient trajectory membership included a less emotional temperament, high cognitive abilities, high self-esteem, low levels of autistic social traits, strong sibling relationships, high maternal care, and positive school experiences. Among the socioeconomic factors considered, maternal education - a significant indicator of socioeconomic status - and birth-order were associated with resilient trajectories. Our findings underscore the importance of fostering cognitive abilities, self-esteem, social relationships, positive school experiences, and extracurricular engagement to bolster resilience in adversity-exposed individuals and communities. This research informs resilience-focused interventions in mental health, education, and social policy sectors, and prompts further exploration of socioeconomic influences on resilience trajectories.

Improving Peer Online Forums (iPOF): protocol for a realist evaluation of peer online mental health forums to inform practice and policy

INTRODUCTION

Peer online mental health forums are commonly used and offer accessible support. Positive and negative impacts have been reported by forum members and moderators, but it is unclear why these impacts occur, for whom and in which forums. This multiple method realist study explores underlying mechanisms to understand how forums work for different people. The findings will inform codesign of best practice guidance and policy tools to enhance the uptake and effectiveness of peer online mental health forums.

METHODS AND ANALYSIS

In workstream 1, we will conduct a realist synthesis, based on existing literature and interviews with approximately 20 stakeholders, to generate initial programme theories about the impacts of forums on members and moderators and mechanisms driving these. Initial theories that are relevant for forum design and implementation will be prioritised for testing in workstream 2.Workstream 2 is a multiple case study design with mixed methods with several online mental health forums differing in contextual features. Quantitative surveys of forum members, qualitative interviews and Corpus-based Discourse Analysis and Natural Language Processing of forum posts will be used to test and refine programme theories. Final programme theories will be developed through novel triangulation of the data.Workstream 3 will run alongside workstreams 1 and 2. Key stakeholders from participating forums, including members and moderators, will be recruited to a Codesign group. They will inform the study design and materials, refine and prioritise theories, and codesign best policy and practice guidance.

ETHICS AND DISSEMINATION

Ethical approval was granted by Solihull Research Ethics Committee (IRAS 314029). Findings will be reported in accordance with RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) guidelines, published as open access and shared widely, along with codesigned tools.

TRIAL REGISTRATION NUMBER

ISRCTN 62469166; the protocol for the realist synthesis in workstream one is prospectively registered at PROSPERO CRD42022352528.

Investigating ethnic inequalities in hearing aid use in England and Wales: a cross-sectional study

OBJECTIVE

To establish whether ethnic inequalities exist in levels of self-reported hearing difficulty and hearing aid use among middle-aged adults.

DESIGN

Cross-sectional data from the UK Biobank resource.

STUDY SAMPLE

164,460 participants aged 40-69 who answered hearing questions at an assessment centre in England or Wales.

RESULTS

After taking into account objectively assessed hearing performance and a corresponding correction for bias in non-native English speakers, as well as a range of correlates including demographic, socioeconomic, and health factors, there were lower levels of hearing aid use for people from Black African (OR 0.36, 95% CI 0.17-0.77), Black Caribbean (OR 0.38, 95% CI 0.22-0.65) and Indian (OR 0.60, 95% CI 0.41-0.86) ethnic groups, compared to the White British or Irish group. Men from most ethnic minority groups and women from Black African, Black Caribbean and Indian groups were less likely to report hearing difficulty than their White British or Irish counterparts.

CONCLUSIONS

For equivalent levels of hearing loss, the use of hearing aids is lower among ethnic minority groups. Inequalities are partly due to lower levels of self-reported hearing difficulty among minority groups. However, even when self-reported hearing difficulty is considered, hearing aid use remains lower among many ethnic minority groups.

Attitudes to climate change risk: classification of and transitions in the UK population between 2012 and 2020

Strategies for achieving carbon emissions goals presuppose changes in individual behaviour, which can be indirectly nudged by interventions or tailored information but ultimately depend upon individual attitudes. Specifically, the perception that climate change is low risk has been identified as a barrier to participation in climate change adaptation and mitigation efforts. Therefore, understanding public attitudes towards climate change risk is an important element of reducing emissions. We applied k-means cluster analysis to explore attitudes to climate change risk in the UK population using data from the UK Household Longitudinal Study, a national survey running from 2009 to present. We identified three distinct attitude clusters: "Sceptical", "Concerned", and "Paradoxical" in both waves 4 (from 2012 to 2014) and 10 (from 2018 to 2020) of this survey. The Sceptical cluster tended to deny the seriousness of climate change and the urgency or even the necessity of dealing with it. The Concerned cluster displayed anxiety about climate change risks and supported action to reduce them. The Paradoxical cluster acknowledged the reality of climate change impacts but did not support actions to mitigate them. We further observed statistical associations between cluster membership and the social characteristics of the participants, including sex, age, income, education, and political affiliation. We also found a temporal stability of cluster structure between the two waves. However, the transition matrices indicated a general transition away from the Sceptical and Paradoxical clusters, and toward the Concerned cluster between wave 4 to wave 10. The findings suggest that more tailored public information campaigns regarding climate change risk may be necessary.

Hospital length of stay for COVID-19 patients: Data-driven methods for forward planning

Background

Predicting hospital length of stay (LoS) for patients with COVID-19 infection is essential to ensure that adequate bed capacity can be provided without unnecessarily restricting care for patients with other conditions. Here, we demonstrate the utility of three complementary methods for predicting LoS using UK national- and hospital-level data.

Method

On a national scale, relevant patients were identified from the COVID-19 Hospitalisation in England Surveillance System (CHESS) reports. An Accelerated Failure Time (AFT) survival model and a truncation corrected method (TC), both with underlying Weibull distributions, were fitted to the data to estimate LoS from hospital admission date to an outcome (death or discharge) and from hospital admission date to Intensive Care Unit (ICU) admission date. In a second approach we fit a multi-state (MS) survival model to data directly from the Manchester University NHS Foundation Trust (MFT). We develop a planning tool that uses LoS estimates from these models to predict bed occupancy.

Results

All methods produced similar overall estimates of LoS for overall hospital stay, given a patient is not admitted to ICU (8.4, 9.1 and 8.0 days for AFT, TC and MS, respectively). Estimates differ more significantly between the local and national level when considering ICU. National estimates for ICU LoS from AFT and TC were 12.4 and 13.4 days, whereas in local data the MS method produced estimates of 18.9 days.

Conclusions

Given the complexity and partiality of different data sources and the rapidly evolving nature of the COVID-19 pandemic, it is most appropriate to use multiple analysis methods on multiple datasets. The AFT method accounts for censored cases, but does not allow for simultaneous consideration of different outcomes. The TC method does not include censored cases, instead correcting for truncation in the data, but does consider these different outcomes. The MS method can model complex pathways to different outcomes whilst accounting for censoring, but cannot handle non-random case missingness. Overall, we conclude that data-driven modelling approaches of LoS using these methods is useful in epidemic planning and management, and should be considered for widespread adoption throughout healthcare systems internationally where similar data resources exist.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12879-021-06371-6).

Length of Stay in ICU of Covid-19 patients in England, March - May 2020

Introduction

Length of Stay (LoS) in Intensive Care Units (ICUs) is an important measure for planning beds capacity during the Covid-19 pandemic. However, as the pandemic progresses and we learn more about the disease, treatment and subsequent LoS in ICU may change.

Objectives

To investigate the LoS in ICUs in England associated with Covid-19, correcting for censoring, and to evaluate the effect of known predictors of Covid-19 outcomes on ICU LoS.

Data sources

We used retrospective data on Covid-19 patients, admitted to ICU between 6 March and 24 May, from the “Covid-19 Hospitalisation in England Surveillance System” (CHESS) database, collected daily from England’s National Health Service, and collated by Public Health England.

Methods

We used Accelerated Failure Time survival models with Weibull and log-normal distributional assumptions to investigate the effect of predictors, which are known to be associated with poor Covid-19 outcomes, on the LoS in ICU.

Results

Patients admitted before 25 March had significantly longer LoS in ICU (mean = 18.4 days, median = 12), controlling for age, sex, whether the patient received Extracorporeal Membrane Oxygenation, and a co-morbid risk factors score, compared with the period after 7 April (mean = 15.4, median = 10). The periods of admission reflected the changes in the ICU admission policy in England. Patients aged 50-65 had the longest LoS, while higher co-morbid risk factors score led to shorter LoS. Sex and ethnicity were not associated with ICU LoS.

Conclusions

The skew of the predicted LoS suggests that a mean LoS, as compared with median, might be better suited as a measure used to assess and plan ICU beds capacity. This is important for the ongoing second and any future waves of Covid-19 cases and potential pressure on the ICU resources. Also, changes in the ICU admission policy are likely to be confounded with improvements in clinical knowledge of Covid-19.

Understanding ethnic inequalities in hearing health in the UK: a cross-sectional study of the link between language proficiency and performance on the Digit Triplet Test

INTRODUCTION

Research using the UK Biobank data has shown ethnic inequalities in hearing health; however, the hearing test used may exhibit a disadvantage for non-native language speakers.

OBJECTIVES

To validate the results of the UK Biobank hearing test (Digit Triplet Test, DTT) against self-reported measures of hearing in the dataset and create classifications of hearing health. To observe if language proficiency and migration age have the same effect on hearing health classification as on the DTT in isolation. Our hypothesis is that language proficiency acts differently on the DTT, demonstrating that the DTT is biased for non-native speakers of English.

DESIGN

Latent classes representing profiles of hearing health were identified from the available hearing measures. Factors associated with class membership were tested using multinomial logistic regression models. Ethnicity was defined as (1) White, native English-speaking, (2) ethnic minority, arrived in the UK aged <12 or (3) ethnic minority, arrived aged >12.

PARTICIPANTS

The UK Biobank participants with valid hearing test results and associated covariates (N=151 268).

OUTCOME MEASURES

DTT score, self-reported hearing difficulty, self-reported hearing difficulty in noise and hearing aid use.

RESULTS

Three classes of hearing health were found: 'normal', 'generally poor' and 'only subjectively poor'. In a model adjusting for known confounders of hearing loss, a poor or insufficient hearing test result was less likely for those with better language (OR 0.69, 95% CI 0.65 to 0.74) or numerical ability (OR 0.71, 95% CI 0.67 to 0.75) but more likely for those having migrated aged >12 (OR 3.85, 95% CI 3.64 to 4.07).

CONCLUSIONS

The DTT showed evidence of bias, having greater dependence on language ability and migration age than other hearing indicators. Designers of future surveys and hearing screening applications may wish to consider the limitations of speech-in-noise tests in evaluating hearing acuity for populations that include non-native speakers.

Is cognitive behavioural therapy effective for individuals experiencing thought disorder?

Various clinical guidelines recommend cognitive behavioural therapy (CBT) to treat psychosis without reference to patients' thought disorder. However, there is a risk that disorganized thinking hampers CBT. We tested the prediction that thought disorder would interfere with the effectiveness of CBT for hallucinations and delusions, compared to treatment as usual and supportive counselling, in secondary data from two large, single blind randomised controlled trials. We fitted latent growth curve models separately for the development of frequency and distress of symptoms. CBT was significantly more successful than counselling in reducing delusional frequency in the short term and hallucinatory distress at any point, even in those with relatively high thought disorder. We found little evidence that clinicians should restrict CBT in this subgroup of patients. Nevertheless, the findings highlight the importance of effective initial treatment of thought disorder in maximising the benefit of CBT for psychosis, particularly for reducing distress from hallucinations.

Distress related to psychotic symptoms in individuals at high risk of psychosis

This study assessed the relationship between distress, severity and frequency of attenuated psychotic symptoms in individuals meeting Ultra High Risk (UHR) criteria, both at baseline and over time. It also assessed distress in relation to attenuated symptoms and whether cognitive behavioural therapy (CBT) reduced distress over time by symptom type. At baseline a combined total of 592 UHR participants (mean age 19.9; males, 53.9%) from two studies were assessed using a confirmatory factor analysis (CFA). Change over time from this baseline point was assessed using latent growth curve (LGC) models, based on participants from one of the studies. Distress associated with psychotic symptom was shown to be a separate psychological construct from severity and frequency. Distress was also significantly associated with severity but not frequency. Longitudinal LGC models with 244 participants showed that distress, severity and frequency all reduced over six months, although the rate of distress reduction varied across symptom type. Non-bizarre ideas (NBI) were more distressing and had the fastest rate of distress reduction over time. The baseline distress for some symptoms also strongly predicted the symptom severity change over time, suggesting that distress may cause change in the UHR criteria for unusual thought content (UTC) and NBI symptoms. CBT was not shown to be significantly different from treatment as usual (TAU) in its effect on distress. However, distress reduces over time, particularly in the first 3 months after presentation. We recommend that distress should be used as an outcome in future research and as a clinical indicator. (250 words).

Older People Living Well Beyond Cancer: The Relationship Between Emotional Support and Quality of Life

Objective: To investigate the influence of emotional support on the quality of life (QoL) of older cancer survivors. Method: We use data from the English Longitudinal Study of Ageing to assess the relationship between perceived emotional support and QoL, comparing people who were cancer survivors (n = 533) to people without cancer (n = 8,203). Results: Most people reported high emotional support and had good QoL (M = 42.57, scale = 0-57). However, linear regression modeling showed cancer survivors had on average slightly lower QoL (-2.10 SE = 0.82). Those who reported having low support reported much poorer QoL; this relationship was similar for both cancer survivors and people without cancer. Discussion: The impact of low emotional support on QoL compounds with the independent detrimental effect of being a cancer survivor. Interventions that increase emotional support are likely to improve QoL for cancer survivors.

Longitudinal predictors of subjective recovery in psychosis

BACKGROUND

Research has highlighted the importance of recovery as defined by the service user, and suggests a link to negative emotion, although little is known about the role of negative emotion in predicting subjective recovery.

AIMS

To investigate longitudinal predictors of variability in recovery scores with a focus on the role of negative emotion.

METHOD

Participants (n = 110) with experience of psychosis completed measures of psychiatric symptoms, social functioning, subjective recovery, depression, hopelessness and self-esteem at baseline and 6 months later. Path analysis was used to examine predictive factors for recovery and negative emotion.

RESULTS

Subjective recovery scores were predicted by negative emotion, positive self-esteem and hopelessness, and to a lesser extent by symptoms and functioning. Current recovery score was not predicted by past recovery score after accounting for past symptoms, current hopelessness and current positive self-esteem.

CONCLUSIONS

Psychosocial factors and negative emotion appear to be the strongest longitudinal predictors of variation in subjective recovery, rather than psychiatric symptoms.

Negative cognition, affect, metacognition and dimensions of paranoia in people at ultra-high risk of psychosis: a multi-level modelling analysis

BACKGROUND

Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).

METHOD

We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.

RESULTS

Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.

CONCLUSIONS

This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.

Why does relative deprivation affect mental health? The role of justice, trust and social rank in psychological wellbeing and paranoid ideation

Purpose

– Relative deprivation is associated with poor mental health but the mechanisms responsible have rarely been studied. The purpose of this paper is to hypothesize that childhood perceived relative deprivation (PRD) would be linked to sub-syndromal psychotic symptoms and poor wellbeing via beliefs about justice, trust and social rank.

Design/methodology/approach

– In total, 683 undergraduate students were administered measures of childhood PRD, hallucination-proneness, paranoia and wellbeing and measures of trust, social rank and beliefs about justice. A subsample supplied childhood address data. Multiple mediation analysis was used to assess pathways from childhood experiences to outcomes.

Findings

– Childhood PRD was associated with all three outcomes. The relationship between PRD and paranoia was fully mediated by perceptions that the world is unjust for the self and low social rank. The same variables mediated the relationship between PRD and poor wellbeing. There were no significant mediators of the relationship between PRD and hallucination-proneness.

Research limitations/implications

– Although our outcome measures have been validated with student samples, it may not be representative. The study is cross-sectional with a retrospective measure of PRD, although similar results were found using childhood addresses to infer objective deprivation. Further studies are required using prospective measures and patient samples.

Social implications

– Social circumstances that promote feelings of low social worth and injustice may confer risk of poor psychological outcome. Ameliorating these circumstances may improve population mental health.

Originality/value

– Improvements in public mental health will require an understanding of the mechanisms linking adversity to poor outcomes. This paper explores some probable mechanisms which have hitherto been neglected.

Psychosocial and neuropsychiatric predictors of subjective recovery from psychosis

Research suggests that both psychosocial factors and neuropsychiatric factors are important predictors of outcome, but little research has examined their relative importance to self-rated recovery. We aim to investigate how such factors are associated with subjective judgements of recovery from psychosis. The participants comprised 122 individuals with experience of psychosis who completed measures of perceived recovery, as well as measures of psychological factors (including self-esteem, locus of control, and emotion) and psychiatric factors (including psychotic symptoms, neurocognition and insight). Measurement models developed using confirmatory factor analysis supported a hypothesis of separate recovery and negative emotion factors. Structural equation modelling showed that negative emotion and internal locus of control had a direct influence on self-rated recovery, and that positive symptoms and internal locus of control had an indirect effect on recovery, mediated via negative emotion. There did not appear to be any effect of insight, negative symptoms or neurocognitive functioning on either self-rated recovery or negative emotion. Psychosocial factors are more directly related to perceived recovery than neuropsychiatric factors. The implications of these findings are discussed.

Mood variability predicts the course of suicidal ideation in individuals with first and second episode psychosis

Suicide risk is high in early psychosis. Recent research has suggested that mood variability may be associated with levels of suicidal thoughts and behaviour. This has not been investigated in individuals during and following a first or second episode of non-affective psychosis. Repeated-measures data over 18 months from a large randomised controlled trial for cognitive behaviour therapy (N=309) were analysed using latent growth curve modelling, whereby both the variability and the level of depression, anxiety and guilt were entered as predictors of suicidality. The variability of depression, but not guilt and anxiety, predicted the course of suicidality even when controlling for a large range of potential confounders. The level of depression, anxiety and guilt for each participant also strongly predicted the development of suicidality. The findings support the theory that variability in depression may contribute to the formation of suicidal ideation and related behaviour. More variable depression may be harder to predict and intervene against, and therefore increase the likelihood that suicidality escalates. The levels of emotions may also be an important determinant. This has implications for the treatment and assessment of suicidality in early psychosis.

The persecution and deservedness scale

OBJECTIVES

To design a brief measure to assess both the severity of paranoid thinking and the perceived deservedness of persecution, which can be employed in clinical and non-clinical populations.

BACKGROUND

No existing measure is adequate for these purposes.

METHODS

In Study 1, we selected 10 items for a persecution and deservedness scale (PaDS) using data from 318 UK and 290 Portuguese undergraduate students, who also completed the Beck Depression Inventory and the Fenigstein's Paranoia Scale. In Study 2, we made comparisons between 45 clinical participants with a diagnosis of schizophrenia, schizoaffective disorder or delusional disorder and the UK students from Study 1. The psychometric properties of the PaDS were analysed for separate persecution (P) and deservedness (D) subscales.

RESULTS

The 10-item PaDS subscales were internally reliable for both clinical and student samples. Correlations with other measures of depressive mood and paranoid thinking indicate that the P subscale has concurrent validity. Higher P and D scores were observed in UK students compared to Portuguese students. The clinical participants' P scores subscale were significantly higher than the students' scores but their D scores were lower.

CONCLUSIONS

The PaDS is a reliable and valid measure of paranoid thinking and perceived deservedness of persecution, which is sensitive for use in clinical and non-clinical populations. Paranoid thinking appears to be mainly bad-me in non-clinical groups but poor-me in psychotic psychiatric patients.