The Publishing Dilemmas of Authors Who Have Lived Experience With Mental Illness

This column details some of the ways in which psychiatric survivors or those writing about their lived experience with mental illness are disadvantaged and devalued in mainstream academic publishing. This devaluation stems from structural issues involving various organizations, persons, and practices. Breaking the constraints of this structure is extremely difficult, but the author proposes some ways of doing so.

PPI in psychiatry and the problem of knowledge

This article begins by locating Patient and Public involvement ((PPI) historically and argues that 'mental health' was a special case. This movement held promise for service users in repositioning them as researchers as opposed to 'subjects'. We argue, however, that ultimately it failed and was reduced to involved publics 'tinkering at the edges'. In respect to this we reference institutions, hierarchies, organisations and the overall political climate. Ultimately, however, it failed at the level of knowledge itself in that t he underlying assumptions of conventional researchers, their aims and goals, clashed with those of the assumptions and aims of survivors. However, we argue that all is not lost, the mainstream itself is imploding and beneath the surface forms of distinctly survivor-led knowledge are emerging.

Decolonising global mental health: The role of Mad Studies

In recent years, there has been a growing and high-profile movement for 'global mental health'. This has been framed in 'psych system' terms and had a particular focus on what has come to be called the 'Global South' or 'low and middle-income countries'. However, an emerging 'Mad Studies' new social movement has also developed as a key challenge to such globalising pressures. This development, however, has itself both being impeded by some of the disempowering foundations of a global mental health approach, as well as coming in for criticism for itself perpetuating some of the same problems as the latter. At the same time, we are also beginning to see it and related concepts like the UNCRPD being given new life and meaning by Global South activists as well as Global North activists. Given such contradictions and complexities, the aim of this paper is to offer an analysis and explore ways forward consistent with decolonizing global mental health and addressing madness and distress more helpfully globally, through a Mad Studies lens.

Is 'another' psychiatry possible?

In this paper, we examine a number of approaches that propose new models for psychiatric theory and practices: in the way that they incorporate 'social' dimensions, in the way they involve 'communities' in treatment, in the ways that they engage mental health service users, and in the ways that they try to shift the power relations within the psychiatric encounter. We examine the extent to which 'alternatives' - including 'Postpsychiatry', 'Open Dialogue', the 'Power, Threat and Meaning Framework' and Service User Involvement in Research - really do depart from mainstream models in terms of theory, practice and empirical research and identify some shortcomings in each. We propose an approach which seeks more firmly to ground mental distress within the lifeworld of those who experience it, with a particular focus on the biopsychosocial niches within which we make our lives, and the impact of systematic disadvantage, structural violence and other toxic exposures within the spaces and places that constitute and constrain many everyday lives. Further, we argue that a truly alternative psychiatry requires psychiatric professionals to go beyond simply listening to the voices of service users: to overcome epistemic injustice requires professionals to recognise that those who have experience of mental health services have their own expertise in accounting for their distress and in evaluating alternative forms of treatment. Finally we suggest that, if 'another psychiatry' is possible, this requires a radical reimagination of the role and responsibilities of the medically trained psychiatrist within and outside the clinical encounter.

Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT

Background

It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).

Objectives

(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).

Design

Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.

Setting

English maternity services and generic and specialist mental health services for pregnant and postnatal women.

Participants

Staff and users of mental health and maternity services.

Interventions

Guided self-help, mother and baby units and generic care.

Main outcome measures

The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.

Results

WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.

Limitations

Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.

Conclusions

Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.

Future work

Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.

Trial registration

This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

Social isolation & loneliness among asylum-seeking parents with young children (0-5 years old)

I will present findings from a qualitative study in Montreal, that aimed to gain a better understanding of the experiences of social isolation and loneliness, key contributors to mental health problems, among asylum seeking families with young children. Using semi-structured interviews, we interviewed 14 families from 11 countries who had children ≤ 5 years old. Social isolation was largely linked to parents' asylum status which contributed to a number of their struggles (poverty, difficulty finding housing, challenges accessing healthcare, family separation, asylum process), and meant they were ineligible for certain benefits and services, particularly subsidized daycare, and as a result left families little time, financial or mental capacity, or support to engage in social interactions. A lack of access to daycare also limited integration of mothers into the workforce and their ability to participate in language courses. Mothers expressed feeling loneliness, which was tied to feelings of sadness and despair due to their precarious situation and uncertain future and having no one to share these worries with, while fathers felt frustrated and spoke about a sense of responsibility to keep moving forward and overcome the family's challenges. Due to parents' isolation, some children were spending lots of time at home, and consequently were being exposed to their parents' stress, which concerned parents as they felt it was affecting their children's well-being. In contrast, children provided a means for breaking families' isolation, either through their participation in recreational activities or because parents were motived to have their children integrated into their new society. Religion/religious organizations were also identified as sources of hope and assistance and contributed to families' well-being. Interventions at the policy, community and individual levels are needed to facilitate families' integration and promote social connectedness and belongingness.

Critical qualitative research on 'madness': knowledge making and activism among those designated 'mad'

This paper charts the background to a project which aimed to map the knowledge being generated across the world by people silenced for centuries - the 'mad': a term with derogatory historical resonances but which is now being reclaimed. The idea that those designated 'mad' can produce knowledge is novel: 'mad' people are imagined as lacking rationality, and incapable of producing knowledge; they are subject to epistemic injustice. Patient engagement in research has grown in the last 20 years but we lack methodological frameworks through which such knowledge can be surfaced. One goal of the project is to let the mad speak their knowledge, often practical knowledge. To do this we had to innovate methodology. Centrally, we refuse the distinction between theory and method for these are constantly intertwined in all research. Thus, what typically comes under 'Method' in background papers is infused with implicit conceptualisation. We carried out 48 interviews in North America, England, Australia, New Zealand, and Eastern and Western Europe. We argue all aspects of these interviews are radically different than is usual for exploratory research in this area. Psychiatry is not central here - it is present only when present in the words of our participants; situated in material and symbolic spaces. We also seek to move away from the individualising therapies of medicines and psychological treatment because they strip participants from their situated realities. Psychiatry enters also because of what it does not do - engage with the life world of its patients. We call then for 'recontextualisation' of madness at all levels. The project was user-led and all researchers had experienced distress and responses to it. Future papers will develop and demonstrate this approach.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

Lost in the shadows: reflections on the dark side of co-production

This article is a response to Oliver et al.'s Commentary 'The dark side of coproduction: do the costs outweigh the benefits for health research?' recently published in Health Research Policy and Systems (2019, 17:33). The original commentary raises some important questions about how and when to co-produce health research, including highlighting various professional costs to those involved. However, we identify four related limitations in their inquiry, as follows: (1) the adoption of a problematically expansive definition of co-production that fails to acknowledge key features that distinguish co-production from broader collaboration; (2) a strong focus on technocratic rationales for co-producing research and a relative neglect of democratic rationales; (3) the transposition of legitimate concerns relating to collaboration between researchers and practitioners onto work with patients, service users and marginalised citizens; and (4) the presentation of bad practice as an inherent flaw, or indeed 'dark side', of co-production without attending to the corrupting influence of contextual factors within academic research that facilitate and even promote such malpractice. The Commentary's limitations can be seen to reflect the contemporary use of the term 'co-production' more broadly. We describe this phenomenon as 'cobiquity' - an apparent appetite for participatory research practice and increased emphasis on partnership working, in combination with the related emergence of a plethora of 'co' words, promoting a conflation of meanings and practices from different collaborative traditions. This phenomenon commonly leads to a misappropriation of the term 'co-production'. Our main motivation is to address this imprecision and the detrimental impact it has on efforts to enable co-production with marginalised and disadvantaged groups. We conclude that Oliver et al. stray too close to 'the problem' of 'co-production' seeing only the dark side rather than what is casting the shadows. We warn against such a restricted view and argue for greater scrutiny of the structural factors that largely explain academia's failure to accommodate and promote the egalitarian and utilitarian potential of co-produced research.

An interpretative phenomenological analysis of the experience of receiving a diagnosis of bi-polar disorder

Background: Research has shown that receiving a psychiatric diagnosis can have both positive and negative consequences for people. The way in which diagnoses are imparted is an under-researched area and may play an important role in reducing stigma and aiding recovery.Aims: The aim of the present study was to get an in-depth understanding of service users' experience of receiving a diagnosis of bipolar disorder.Methods: Nine service users recently diagnosed with bipolar disorder were interviewed using a semi-structured interview schedule designed to elicit information regarding the positive and negative aspects of receiving their diagnosis. All transcripts were analysed using Interpretative Phenomenological Analysis (IPA).Findings: The findings can be described in terms of three master themes: 1. "Perceived fit between diagnosis and lived experience", 2. "Evaluating the utility of carrying the diagnostic label" and 3. "The role of diagnosis in searching for solutions to one's difficulties".Conclusion: This study draws attention to the importance of evaluating the fit between diagnosis and personal experiences and to the relevance of perceived stigma. The findings also highlight the significance of the client-clinician relationship in establishing fit and instilling hope, which has implications for the acceptance of the diagnosis and engagement with services.

Exploring the potential use of patient and public involvement to strengthen Indonesian mental health care for people with psychosis: A qualitative exploration of the views of service users and carers

BACKGROUND

Patient and public involvement (PPI) has the potential to strengthen mental health systems in Indonesia and improve care for people living with psychosis. Current evidence from other parts of the world demonstrates the need to understand the contexts in which PPI is to be enacted to ensure optimal implementation.

OBJECTIVE

To understand service users' and carers' views on the current use and potential applicability of PPI within Indonesian mental health services.

DESIGN

Qualitative study incorporating focus groups analysed using thematic analysis.

SETTING AND PARTICIPANTS

Participants included 22 service users and 21 carers recruited from two study sites in Indonesia (Jakarta and Bogor). All participants had experience of psychosis either as a service user or carer.

RESULTS

Despite the value attributed to PPI in relation to improving services and promoting recovery, current use of such activities in Indonesian mental health services was limited. Participants expressed a desire for greater levels of involvement and more holistic care but felt community organizations were best placed to deliver this because PPI was considered more congruent with the ethos of third-sector organizations. Additional barriers to PPI included stigma and low levels of mental health literacy in both health services and communities.

DISCUSSION AND CONCLUSION

Participants felt that there was potential value in the use of PPI within Indonesian mental health services with careful consideration of individual contexts. Future aspirations of involvement enactment should ensure a central design and delivery role for third-sector organizations. Facilitators to global collaborative research in the context of the current study are also discussed.

Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence

INTRODUCTION

Civic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular.

METHODS

We completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach-realist synthesis-to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset.

RESULTS

Fifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure.

CONCLUSION

Our findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making.Registration This review is registered on PROSPERO: CRD42018087841.

Search for Subsolar Mass Ultracompact Binaries in Advanced LIGO's Second Observing Run

We present a search for subsolar mass ultracompact objects in data obtained during Advanced LIGO's second observing run. In contrast to a previous search of Advanced LIGO data from the first observing run, this search includes the effects of component spin on the gravitational waveform. We identify no viable gravitational-wave candidates consistent with subsolar mass ultracompact binaries with at least one component between 0.2  M_{⊙}-1.0  M_{⊙}. We use the null result to constrain the binary merger rate of (0.2  M_{⊙}, 0.2  M_{⊙}) binaries to be less than 3.7×10^{5}  Gpc^{-3} yr^{-1} and the binary merger rate of (1.0  M_{⊙}, 1.0  M_{⊙}) binaries to be less than 5.2×10^{3}  Gpc^{-3} yr^{-1}. Subsolar mass ultracompact objects are not expected to form via known stellar evolution channels, though it has been suggested that primordial density fluctuations or particle dark matter with cooling mechanisms and/or nuclear interactions could form black holes with subsolar masses. Assuming a particular primordial black hole (PBH) formation model, we constrain a population of merging 0.2  M_{⊙} black holes to account for less than 16% of the dark matter density and a population of merging 1.0  M_{⊙} black holes to account for less than 2% of the dark matter density. We discuss how constraints on the merger rate and dark matter fraction may be extended to arbitrary black hole population models that predict subsolar mass binaries.

A-21 Inhibition of Overlearned Verbal Responses and Quantity of Speech Among Age Cohorts

Objective

Off-topic speech (OTS) has been linked with deficits in executive functioning, and specifically inhibition. OTS research has focused primarily on tangentiality, whereas in this study we focused on quantity of speech. The purpose of this study was to investigate the relationship between inhibition of overlearned responses using a Stroop task and quantity of speech.

Method

A college sample of young adults (n = 63; age 18-28) and healthy, community-dwelling older adults (n = 76; age 60-99) completed the Delis-Kaplan Executive Function Systems (D-KEFS) Color-Word Interference Test and provided a verbal sample in which they recounted a procedural memory and an episodic memory. These samples were transcribed and rated for quantity of speech by three independent judges.

Results

Among all participants, longer time to complete color naming (r = -.21, p = .02) and inhibition (r = -.21, p = .01) was associated with lower quantity of speech on procedural memory. Among young adults, longer time to complete inhibition was associated with lower quantity of speech (r = -.26, p = .04). Among older adults, longer time to complete color naming (r = -.32, p = .005), word reading (r = -.27, p = .02), and inhibition (r = -.35, p = .002) was associated with lower quantity of speech. No relationships were found between performance on Stroop conditions and quantity of speech for episodic memory.

Conclusions

Results suggest that among both age cohorts, difficulty inhibiting overlearned verbal responses is associated with lower quantity of speech regarding a procedural memory but not an episodic memory.

Public involvement in health outcomes research: lessons learnt from the development of the recovering quality of life (ReQoL) measures

Background

To provide a model for Public involvement (PI) in instrument development and other research based on lessons learnt in the co-production of a recently developed mental health patient reported outcome measure called Recovering Quality of Life (ReQoL). While service users contributed to the project as research participants, this paper focuses on the role of expert service users as research partners, hence referred to as expert service users or PI.

Methods

At every stage of the development, service users influenced the design, content and face validity of the measure, collaborating with other researchers, clinicians and stakeholders who were central to this research. Expert service users were integral to the Scientific Group which was the main decision-making body, and also provided advice through the Expert Service User Group.

Results

During the theme and item generation phase (stage 1) expert service users affirmed the appropriateness of the seven domains of the Patient Reported Outcome Measure (activity, hope, belonging and relationships, self-perception, wellbeing, autonomy, and physical health). Expert service users added an extra 58 items to the pool of 180 items and commented on the results from the face and content validity testing (stage 2) of a refined pool of 88. In the item reduction and scale generation phase (stage 3), expert service users contributed to discussions concerning the ordering and clustering of the themes and items and finalised the measures. Expert service users were also involved in the implementation and dissemination of ReQoL (stage 4). Expert service users contributed to the interpretation of findings, provided inputs at every stage of the project and were key decision-makers. The challenges include additional work to make the technical materials accessible, extra time to the project timescales, including time to achieve consensus from different opinions, sometimes strongly held, and extra costs.

Conclusion

This study demonstrates a successful example of how PI can be embedded in research, namely in instrument development. The rewards of doing so cannot be emphasised enough but there are challenges, albeit surmountable ones. Researchers should anticipate and address those challenges during the planning stage of the project.

Protocol for a quasi-experimental study of the effectiveness and cost-effectiveness of mother and baby units compared with general psychiatric inpatient wards and crisis resolution team services (The ESMI study) in the provision of care for women in the postpartum period

INTRODUCTION

Research into what constitutes the best and most effective care for women with an acute severe postpartum mental disorder is lacking. The effectiveness and cost-effectiveness of psychiatric mother and baby units (MBUs) has not been investigated systematically and there has been no direct comparison of the outcomes of mothers and infants admitted to these units, compared with those accessing generic acute psychiatric wards or crisis resolution teams (CRTs). Our primary hypothesis is that women with an acute psychiatric disorder, in the first year after giving birth, admitted to MBUs are significantly less likely to be readmitted to acute care (an MBU, CRTs or generic acute ward) in the year following discharge than women admitted to generic acute wards or cared for by CRTs.

METHODS AND ANALYSIS

Quasi-experimental study of women accessing different types of acute psychiatric services in the first year after childbirth. Analysis of the primary outcome will be compared across the three service types, at 1-year postdischarge. Cost-effectiveness will be compared across the three service types, at 1-month and 1-year postdischarge; explored in terms of quality-adjusted life years. Secondary outcomes include unmet needs, service satisfaction, maternal adjustment, quality of mother-infant interaction. Outcomes will be analysed using propensity scoring to account for systematic differences between MBU and non-MBU participants. Analyses will take place separately within strata, defined by the propensity score, and estimates pooled to produce an average treatment effect with weights to account for cohort attrition.

ETHICS AND DISSEMINATION

The study has National Health Service (NHS) Ethics Approval and NHS Trust Research and Development approvals. The study has produced protocols on safeguarding maternal/child welfare. With input from our lived experience group, we have developed a dissemination strategy for academics/policy-makers/public.

Diagnostic performance of the molecular BCR-ABL1 monitoring system may impact on inclusion of CML patients in stopping trials

In chronic myeloid leukemia (CML), the duration of deep molecular response (MR) before treatment cessation (MR⁴ or deeper, corresponding to BCR-ABL1 ≤ 0.01% on the International Scale (IS)) is considered as a prognostic factor for treatment free remission in stopping trials. MR level determination is dependent on the sensitivity of the monitoring technique. Here, we compared a newly established TaqMan (TM) and our so far routinely used LightCycler (LC) quantitative reverse transcription (qRT)-PCR systems for their ability to achieve the best possible sensitivity in BCR-ABL1 monitoring. We have comparatively analyzed RNA samples from peripheral blood mononuclear cells of 92 randomly chosen patients with CML resembling major molecular remission (MMR) or better and of 128 CML patients after treatment cessation (EURO-SKI stopping trial). While our LC system utilized ABL1, the TM system is based on GUSB as reference gene. We observed 99% concordance with respect to achievement of MMR. However, we found that 34 of the 92 patients monitored by TM/GUSB were re-classified to the next inferior MR log level, especially when LC/ABL1-based results were borderline to thresholds. Thirteen patients BCR-ABL1 negative in LC/ABL1 became positive after TM/GUSB analysis. In the 128 patients included in the EURO-SKI trial identical molecular findings were achieved for 114 patients. However, 14 patients were re-classified to the next inferior log-level by the TM/GUSB combination. Eight of these patients relapsed after treatment cessation; two of them were re-classified from MR⁴ to MMR and therefore did not meet inclusion criteria anymore. In conclusion, we consider both methods as comparable and interchangeable in terms of achievement of MMR and of longitudinal evaluation of clinical courses. However, in LC/ABL1 negative samples, slightly enhanced TM/GUSB sensitivity may lead to inferior classification of clinical samples in the context of TFR.

Power, Privilege and Knowledge: the Untenable Promise of Co-production in Mental "Health"

This paper examines the concept and practice of coproduction in mental health. By analyzing personal experience as well as the historical antecedents of coproduction, we argue that the site of coproduction is defined by the legacy of the Enlightenment and its notions of "reason" and "the cognitive subject." We show the enduring impact of these notions in producing and perpetuating the power dynamics between professionals, researchers, policy makers and service users within privileged sites of knowledge production, whereby those deemed to lack reason-the mad and the racialized mad in particular-and their knowledge are radically inferiorised. Articulating problems in what is considered knowledge and methods of knowing, we argue that modern "psy" sciences instantiates the privilege of reason as well as of whiteness. We then examine how the survivor movement, and the emergent survivor/mad knowledge base, duplicates white privilege even as it interrogates privileges of reason and cognition. Describing how we grapple with these issues in an ongoing project-EURIKHA-which aims to map the knowledge produced by service users, survivors and persons with psychosocial disabilities globally, we offer some suggestions. Coproduction between researchers, policy makers and those of us positioned as mad, particularly as mad people of color, we argue, cannot happen in knowledge production environments continuing to operate within assumptions and philosophies that privilege reason as well as white, Eurocentric thinking. We seek not to coproduce but to challenge and change thinking and support for psychosocial suffering in contexts local to people's lives.

Changing nurses' views of the therapeutic environment: randomised controlled trial

BACKGROUND

Although patients value evidence-based therapeutic activities, little is known about nurses' perceptions.AimsTo investigate whether implementing an activities training programme would positively alter staff perceptions of the ward or be detrimental through the increased workload (trial registration: ISRCTN 06545047).

METHOD

We conducted a stepped wedge cluster randomised trial involving 16 wards with psychology-led nurse training as the intervention. The main outcome was a staff self-report measure of perceptions of the ward (VOTE) and secondary outcomes measuring potential deterioration were the Index of Work Satisfaction (IWS) and the Maslach Burnout Inventory (MBI). Data were analysed using mixed-effects regression models, with repeated assessments from staff over time.

RESULTS

There were 1075 valid outcome measurements from 539 nursing staff. VOTE scores did not change over time (standardised effect size 0.04, 95% CI -0.09 to 0.18, P = 0.54), neither did IWS or MBI scores (IWS, standardised effect size 0.02, 95% CI -0.11 to 0.16, P = 0.74; MBI standardised effect size -0.09, 95% CI -0.24 to 0.06, P = 0.24). There was a mean increase of 1.5 activities per ward (95% CI -0.4 to 3.4, P = 0.12) and on average 6.3 more patients attended groups (95% CI -4.1 to 16.6, P = 0.23) following training. Staff feedback on training was positive.

CONCLUSIONS

Our training programme did not change nurses' perceptions of the ward, job satisfaction or burnout. During the study period many service changes occurred, most having a negative impact through increased pressure on staffing, patient mix and management so it is perhaps unsurprising that we found no benefits or reduction in staff skill.Declaration of interestNone.

A hidden activism and its changing contemporary forms: Mental health service users / survivors mobilising

This commentary concerns how the organisation of State welfare benefits in the UK have changed over the last 20 years, arguing that this has had harmful, even fatal, consequences for people with disabilities and particularly those with mental distress of psychosocial disabilities. This current situation may be called that of austerity. The paper describes how a ‘hidden activism’ has emerged to contest this situation and explains why it is, and to a degree, must be hidden. I then focus on the discourse of responsibilisation where every citizen must take responsibility for embodying the virtues of the good, working person. To ensure this, unemployment has been framed as a psychological problem and psychologists are now employed to ‘treat’ this problem in order that everybody might enter the world of work. I argue that in current conditions this is not possible for all with mental distress. Engaging then with community psychology, I address the issue of allies and how the absence of attention to mental distress might be remedied by this form of work. I draw on the emerging field of user / survivor-led research in mental health and argue that collaboration with community psychology will not be without problems.

Patient involvement in improving the evidence base on mental health inpatient care: the PERCEIVE programme

Background

Despite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programme provides a particular focus on the inclusion of the patient’s perspective in the development and evaluation of evidence.

Objectives

To understand how changes to inpatient care affect the perceptions of the ward by service users and staff by using stakeholder participatory methods.

Design

The programme consisted of four work packages (WPs). (1) Lasting Improvements for Acute Inpatient SEttings (LIAISE): using participatory methods we developed two new scales [Views On Therapeutic Environment (VOTE) for staff and Views On Inpatient CarE (VOICE) for service users]. (2) Client Services Receipt Inventory – Inpatient (CITRINE): working with nurses and service users we developed a health economic measure of the amount of contact service users have with staff. The self-report measure records interactions with staff as well as the number of therapeutic activities attended. (3) Delivering Opportunities for Recovery (DOORWAYS): a stepped-wedge randomised controlled trial to test if training ward nurses to deliver therapeutic group activities would improve the perception of the ward by service users and staff. A total of 16 wards were progressively randomised and we compared the VOICE, VOTE and CITRINE measures before and after the intervention. A total of 1108 service users and 539 staff participated in this trial. (4) Bringing Emergency TreatmenT to Early Resolution (BETTER PATHWAYS) was an observational study comparing two service systems. The first was a ‘triage’ system in which service users were admitted to the triage ward and then either transferred to their locality wards or discharged back into the community within 7 days. The second system was routine care. We collected data from 454 service users and 284 nurses on their perceptions of the wards.

Main outcome measures

The main outcomes for the DOORWAYS and BETTER project were service user and staff perceptions of the ward (VOICE and VOTE, respectively) and the health economic measure was CITRINE. All were developed in WPs 1 and 2.

Results

We developed reliable and valid measures of (1) the perceptions of inpatient care from the perspectives of service users and nurses (VOICE and VOTE) and (2) costs of interactions that were valued by service users (CITRINE). In the DOORWAYS project, after adjusting for legal status, we found weak evidence for benefit (standardised effect of –0.18, 95% CI 0.38 improvement to 0.01 deterioration;p = 0.062). There was only a significant benefit for involuntary patients following the staff training (N582, standardised effect of –0.35, 95% CI –0.57 to –0.12;p = 0.002; interactionp-value 0.006). VOTE scores did not change over time (standardised effect size of 0.04, 95% CI –0.09 to 0.18;p = 0.54). We found no evidence of an improvement in cost-effectiveness (estimated effect of £33, 95% CI –£91 to £146;p = 0.602), but resource allocation did change towards patient-perceived meaningful contacts by an average of £12 (95% CI –£76 to £98;p = 0·774). There were no significant differences between the triage and routine models of admission in terms of better perceptions by service users (estimated effect 0.77-point improvement in VOICE score on the triage ward;p = 0.68) or nurses (estimated effect of 1.68-point deterioration in VOTE on the triage ward;p = 0.38) or in terms of the cost of the length of care provided (£391 higher on triage;p = 0.77).

Strengths and limitations

We have developed measures using methods involving both service users and staff from mental health services. The measures were developed specifically for acute inpatient services and, therefore, cannot be assumed to be useful for other services. For instance, extensions of the measures are under construction for use in mother and baby units. The strength of the BETTER PATHWAYS and DOORWAYS projects is the large-scale data collection. However, we were testing specific services based in inner city areas and stretching to inner urban areas. It may be that different effects would be found in more rural communities or in different types of inpatient care.

Future work

Our database will be used to develop an understanding of the mediating and moderating factors for improving care quality.

Trial registration

Current Controlled Trials ISRCTN06545047.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 7. See the NIHR Journals Library website for further project information.

Exploring the potential of civic engagement to strengthen mental health systems in Indonesia (IGNITE): a study protocol

Background

Indonesia has the highest rate of years of life lost to disability or early death from Schizophrenia than any other country in the world. More than 90% of people with mental illness do not get any treatment and tens of thousands of people with psychosis are illegally detained (‘pasung’) in the family home. Civic engagement, a core part of the recent World Health Organisation global strategy, has the potential to address some of these challenges through the development of person-centered models of care. The aim of the study is to develop a testable systems level, culturally appropriate, civic engagement framework for use in Jakarta and Bogor, Indonesia to strengthen local mental health services.

Methods

A mixed methods study underpinned by a realist approach will be undertaken across four phases in two study sites in Indonesia (Jakarta and Bogor). Phase 1 will explore the use of civic engagement across South East Asia by conducting a systematic review of existing evidence. By surveying 300 mental health professionals, phase 2 will identify the stakeholders, the sources of collaboration and the evidence used by professionals in decision making within local mental health systems and identify potential opportunities for civic engagement within the system. In order to explore the potential use of civic engagement within Indonesian mental health services and identify priorities for a culturally appropriate framework, phase 3 will undertake two focus groups with participants with experience of psychosis or caring for someone with psychosis (n = 20–30). Professionals and other key decision makers in a range of roles across the system at a national (n = 5) and local level (n = 10–15/site) will also take part in semi-structured interviews. Phase 4 will co-produce a civic engagement framework for use in Indonesia by synthesising evidence from phases 1–3 collaboratively with key stakeholders.

Discussion

Civic engagement is a potential way in which health services in low and middle income countries can address the burden of mental health conditions through the development of person-centred models of care. However, such approaches are underexplored in Indonesia. This study will work with local stakeholders to design a testable civic engagement framework for use in mental health services in Indonesia.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0227-x) contains supplementary material, which is available to authorized users.

Participatory research: real or imagined

BACKGROUND

Participatory research has as a central tenet that power relations between researcher and researched be reduced. In the last 20 years, a substantial literature has demonstrated the difficulties inherent in this as well as the troublesome nature of certain central concepts.

AIMS

(1) To describe and illustrate a new form of participatory research where the researchers share at least something with the participants in the research. That is, all are users of mental health services. (2) To reflect on the novel form of participatory research in terms of whether it shares, mitigates or avoids some of the difficulties of more traditional forms and to pose the question: what is a mental health community?

RESULTS

The model described is new in that the researchers have a different status than in conventional participatory research. But it is illuminated by and itself illuminates issues of power relations in research and difficulties in reducing that; gatekeepers and the exclusion of crucial groups of service users; the confusion of demographic representativeness with the silencing of marginalized perspectives; coming out of the academic space and the shifting issue of what counts as 'communities' in mental health.

CONCLUSION

The examples given are moderate in scale and relevant to social psychiatry. Yet they may change methods and the definition of participatory research and at the same time be vitiated by but also illuminate dilemmas already identified in the literature albeit in different formations.

"This is not a Life Anyone would want"-A Qualitative Study of Norwegian ACT Service users' Experience with Mental Health Treatment

We discuss Norwegian service users' experiences with community mental health treatment in general, and the interprofessional Assertive Community Treatment (ACT) model in particular. To gain the right to treatment, service users have to accept certain limitations, such as medication and community treatment orders (CTOs). Seventy participants responded to five open-ended questions. In addition, eight of them participated in either focus group or interviews. A collaborative approach, using Stepwise-Deductive Induction (SDI) method was used to analyze the participants' experiences. The results showed that the treatment contributes to an experience of autonomy but also one of restriction. It provides service users with enhanced normalcy, but simultaneously a feeling of deviance. There needs to be an ongoing reflection and discussion about those paradoxes in treatment, and service users have to be involved.

The importance of content and face validity in instrument development: lessons learnt from service users when developing the Recovering Quality of Life measure (ReQoL)

PURPOSE

Service user involvement in instrument development is increasingly recognised as important, but is often not done and seldom reported. This has adverse implications for the content validity of a measure. The aim of this paper is to identify the types of items that service users felt were important to be included or excluded from a new Recovering Quality of Life measure for people with mental health difficulties.

METHODS

Potential items were presented to service users in face-to-face structured individual interviews and focus groups. The items were primarily taken or adapted from current measures and covered themes identified from earlier qualitative work as being important to quality of life. Content and thematic analysis was undertaken to identify the types of items which were either important or unacceptable to service users.

RESULTS

We identified five key themes of the types of items that service users found acceptable or unacceptable; the items should be relevant and meaningful, unambiguous, easy to answer particularly when distressed, do not cause further upset, and be non-judgemental. Importantly, this was from the perspective of the service user.

CONCLUSIONS

This research has underlined the importance of service users' views on the acceptability and validity of items for use in developing a new measure. Whether or not service users favoured an item was associated with their ability or intention to respond accurately and honestly to the item which will impact on the validity and sensitivity of the measure.

Long-Term Follow-Up of Iodine-125 Brachytherapy for Choroidal Melanomas. Part I: Anatomical Results and Life Expectancy

We report a prospective study of 19 choroidal melanomas treated with iodine-125 plaque from 1984 to 1989. The mean tumor height was 5.8 mm, base diameter 11.6 mm, and tumor volume 80 to 510 mm3. The mean radiation dose to tumor apex was 70 Gy and scleral contact dose 355 Gy; tumor base was surrounded by contiguous laser or cryopexy lesions. Follow-up was 27 to 84 months (mean 60 months). All tumors regressed at least 50% in volume with no tumor regrowth within 27 months to 60 months. Late tumor regrowth, localized in the center, occurred in one eye after 65 and another after 69 months. One tumor was successfully replaqued; the other was not re-treated because the patient had had a recent heart attack. In 17 eyes radiation retinopathy developed after 1½ years, the earliest in a diabetic eye. Despite primary recovery of preoperative vision, there was severe deterioration of visual acuity after 4½ years in all the eyes. During follow-up, two patients died due to metastases after 28 and 71 months; one patient is alive with metastases after 17 months. None of the eyes had to be enucleated. There was no incidence of madaurosis, Symblepharon, or dry eye.

The CIRCuiTS study (Implementation of cognitive remediation in early intervention services): protocol for a randomised controlled trial

Background

Cognitive problems in people with schizophrenia predict poor functional recovery even with the best possible rehabilitation opportunities and optimal medication. A psychological treatment known as cognitive remediation therapy (CRT) aims to improve cognition in neuropsychiatric disorders, with the ultimate goal of improving functional recovery. Studies suggest that intervening early in the course of the disorder will have the most benefit, so this study will be based in early intervention services, which treat individuals in the first few years following the onset of the disorder. The overall aim is to investigate different methods of CRT.

Methods

This is a multicentre, randomised, single-blinded, controlled trial based in early intervention services in National Health Service Mental Health Trusts in six English research sites. Three different methods of providing CRT (intensive, group, and independent) will be compared with treatment as usual. We will recruit 720 service users aged between 16 and 45 over 3 years who have a research diagnosis of non-affective psychosis and will be at least 3 months from the onset of the first episode of psychosis. The primary outcome measure will be the degree to which participants have achieved their stated goals using the Goal Attainment Scale. Secondary outcome measures will include improvements in cognitive function, social function, self-esteem, and clinical symptoms.

Discussion

It has already been established that cognitive remediation improves cognitive function in people with schizophrenia. Successful implementation in mental health services has the potential to change the recovery trajectory of individuals with schizophrenia-spectrum disorders. However, the best mode of implementation, in terms of efficacy, service user and team preference, and cost-effectiveness is still unclear. The CIRCuiTS trial will provide guidance for a large-scale roll-out of CRT to mental health services where cognitive difficulties impact recovery and resilience.

Trial registration

ISRCTN, ISRCTN14678860, Registered on 6 June 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2553-3) contains supplementary material, which is available to authorized users.

Recovery concept in a Norwegian setting to be examined by the assertive community treatment model and mixed methods

Recovery is a crucial concept in the mental health field. The research of recovery is split into the categories of personal, social and clinical recovery. The purpose of this study was to explore the fragmented concept of recovery in light of assertive community treatment (ACT) in Norway. The study has a mixed methods design with a pragmatic approach. The Questionnaire about the Process of Recovery and open-ended questions posed to 70 participants from 12 ACT teams in Norway, gathered by the "Users interview users" method, are combined with interviews or focus groups with eight of these participants. Surprisingly those under a community treatment order (CTO) report the highest degree of personal recovery. The qualitative material shows that the service users interpreted the concept of recovery differently than researchers and professionals. The ACT service users highlighted three important elements: flexible treatment, medication and access to a car. They emphasized the necessity for basic needs to be met in order to experience a meaningful recovery process, and these basic needs may be of even greater importance to those under CTOs. Their experiences should imply a greater emphasis on securing basic needs such as secure housing, sounder finances and access to the normal benefits offered by society.

Improving patient experiences of mental health inpatient care: a randomised controlled trial

BACKGROUND

Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients' views of ward care.

METHOD

Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.

RESULTS

In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect -0·35, 95% CI -0·57 to -0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, -0.01, 95% CI -0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect -0.18 s.d., 95% CI -0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI -£76 to £98, p = 0.774).

CONCLUSION

Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.

Collaborative research between users and professionals: peaks and pitfalls

In this article, I shall give an overview of the emerging field of collaborative research between clinical academics and service users in the field of mental health, along with some examples of different kinds of collaborative research and the value they can bring to more mainstream studies. I shall also discuss some of the obstacles to collaborative research in mental health and suggest directions for the future.

Discrimination against people with mental illness: what can psychiatrists do?

This article discusses the evidence that experiences of stigmatisation and discrimination among people with mental illnesses are common and may be severe. Furthermore, there are growing concerns that people with mental illness receive second-class physical healthcare. Beyond this, some aspects of psychiatric practice are reported as being insensitive, disrespectful or even disabling. We consider whether such claims are justified and what psychiatrists can do, directly and indirectly, to reduce stigma and discrimination and improve our practice.

The effects of fermentation and enzymatic treatment of pea on nutrient digestibility and growth performance of broilers

The present study examined the impacts of native, fermented or enzymatically treated peas (Pisum sativum L.) inclusion in broiler diets, on growth performance and nutrient digestibility. For the fermentation process, Madonna pea was mixed with water (1/1) containing 2.57×108 Bacillus subtilis (GalliPro®) spores/kg pea and then, incubated for 48 h at 30 °C. For the enzymatic treatment process, the used water for dough production contained three enzymes, AlphaGalTM (α-galactosidase), RONOZYME® ProAct and VP (protease and pectinases respectively - DSM, Switzerland) and the pea dough incubated for 24 h at 30°C. Nine corn-wheat-soybean diets were formulated by supplying 10%, 20% and 30% of the required CP with either native, fermented or enzymatically treated peas. Performance was recorded weekly and at the end of the experiment (day 35), apparent ileal digestibility (AID) of CP, amino acids (AA), crude fat, starch, Ca, P and K were determined. Data were subjected to ANOVA using GLM procedure with a 3×3 factorial arrangement of treatments. Both processes reduced α-galactosides, phytate, trypsin inhibitor activity and resistant starch in peas. Increasing levels of pea products up to 300 g/kg diet, reduced BW gain and feed intake (P⩽0.05). Broilers fed diets containing enzymatically treated pea had the best feed conversion ratio at day 35. Different types of pea product and their inclusion levels had no effect on AID of all nutrients. The interaction between type of the pea products and inclusion levels was significant for AID of starch. For native pea diets, 10% group showed similar AID of starch to 20% native pea but it had higher AID than 30% native pea. For fermented and enzymatically treated groups, all three levels displayed similar AID of starch. In conclusion, enzymatic treatment and fermentation could improve the nutritional quality of pea. Inclusion of enzymatically treated pea in broiler diets could improve broiler performance compared with other pea products while, it displayed neither positive nor negative impact on nutrient digestibility. The present findings indicate the feasibility of these processes, particularly enzymatic treatment, for improving the nutritional quality of pea as a protein source for broiler nutrition.

What side effects are problematic for patients prescribed antipsychotic medication? The Maudsley Side Effects (MSE) measure for antipsychotic medication

BACKGROUND

Capturing service users' perspectives can highlight additional and different concerns to those of clinicians, but there are no up to date, self-report psychometrically sound measures of side effects of antipsychotic medications. Aim To develop a psychometrically sound measure to identify antipsychotic side effects important to service users, the Maudsley Side Effects (MSE) measure.

METHOD

An initial item bank was subjected to a Delphi exercise (n = 9) with psychiatrists and pharmacists, followed by service user focus groups and expert panels (n = 15) to determine item relevance and language. Feasibility and comprehensive psychometric properties were established in two samples (N43 and N50). We investigated whether we could predict the three most important side effects for individuals from their frequency, severity and life impact.

RESULTS

MSE is a 53-item measure with good reliability and validity. Poorer mental and physical health, but not psychotic symptoms, was related to side-effect burden. Seventy-nine percent of items were chosen as one of the three most important effects. Severity, impact and distress only predicted 'putting on weight' which was more distressing, more severe and had more life impact in those for whom it was most important.

CONCLUSIONS

MSE is a self-report questionnaire that identifies reliably the side-effect burden as experienced by patients. Identifying key side effects important to patients can act as a starting point for joint decision making on the type and the dose of medication.

Service user perspectives on coercion and restraint in mental health

Coercion remains a central aspect of many people's mental healthcare. It can include the use of legislation to restrict freedoms, the use of physical restraint, the restriction of freedom of movement and/or association, and the forced or covert administration of medication. There is good evidence that the use of such measures can traumatise service users. This article reports the findings of a survey of service users regarding their experiences of coercion and restraint and embeds this in the wider international and institutional environment.

Seeking help for obsessive compulsive disorder (OCD): a qualitative study of the enablers and barriers conducted by a researcher with personal experience of OCD

OBJECTIVES

Obsessive compulsive disorder (OCD) can be hugely disabling. Although very effective psychological treatments exist, many people delay years before seeking help or never seek treatment. There have been clinical observation and short questionnaire studies on why people delay, but little qualitative research exists on this complex subject. The present qualitative study aimed to identify the barriers to seeking treatment and the factors that encourage or push people to seek help for their OCD (positive and negative enablers).

DESIGN

A qualitative, exploratory study using in-depth, individual, semi-structured interviews was conducted by a researcher with personal experience of OCD.

METHODS

Seventeen people with OCD, contacted through the charity OCD-UK, were interviewed about the factors that impacted on their decision to seek help or not. The interviews were analysed using thematic analysis.

RESULTS

Barriers identified were stigma, 'internal / cognitive' factors, not knowing what their problem was, factors relating to their GP or treatment, and fear of criminalisation. Positive enablers identified were being supported to seek help, information and personal accounts of OCD in the media, and confidence in their GP. Negative enablers were reaching a crisis point and for some participants (whose intrusive thoughts were about harming children) feeling driven to seek treatment because of the nature of the thoughts, that is, seeking help to prevent the 'harm' they feared they were capable of doing.

CONCLUSIONS

Participants identified a range of barriers and enablers that impacted on their decision to seek help or not. These give important indicators about the likely causes for delayed help seeking in OCD and ways in which people might be encouraged to seek help earlier.

PRACTITIONER POINTS

People with OCD may face a wide range of barriers to seeking help, including concern about the reaction of health professionals. The level of awareness, kindness, and understanding shown by first-line practitioners can be very important to those seeking help. Acknowledging a person's journey prior to seeking help is likely to foster trust between therapist and patient. Some barriers to seeking help, for example, fear of criminalisation, may continue to have an important effect afterwards unless sensitively explored and understood.

Abstract P4-18-02: Peer navigation for people affected by hereditary breast, ovarian and related cancers: Results from the first six months

People affected by hereditary breast, ovarian, and related cancers (HBOC) due to a mutation in BRCA, or another gene that increases cancer risk, have unique support and information needs and face medical decisions that differ from survivors of sporadic breast cancer and from people at average risk for these cancers. Finding peers to talk to can be challenging, especially for people living outside of metropolitan areas.

FORCE (Facing Our Risk of Cancer Empowered) developed our Peer Navigation Program to provide personalized, expert-reviewed resources and 1:1 support for people affected by HBOC, including breast cancer survivors and people at high risk for breast cancer due to a mutation in BRCA or another gene that increases cancer risk.

The program utilizes a custom database that matches individuals seeking support with trained Peer Navigators who have faced similar medical challenges and decisions. Users complete an intake form, providing basic demographic, medical, and geographic information in order to match them as closely as possible to a peer volunteer. The user selects from 21 specific topics of interest to them. This generates a personalized, expert-reviewed resource guide on each selected topics, which individuals can use to make informed, shared decisions with their healthcare providers.

Trained Peer Navigators conduct one-hour phone calls with program users to discuss the personalized resources and provide non-judgmental emotional support. Our goal is to match users and complete the navigation process within one week from the time they submitted their intake form. After a navigation session, both the Peer Navigator and the program participant are asked to fill out an evaluation.

All Peer Navigator volunteers undergo a written and telephone interview to assure their readiness to help others. Once they pass this screening process, they complete a series of online VolunteerFORCE Academy training webinars and complete a profile form providing information about their demographics, personal and medical situation, and medical decisions.

Volunteers receive training on the following: FORCE 101, HBOC 101, Active Listening Skills and Peer Navigation instructions. All webinars have been reviewed and approved by a member of FORCE's Scientific Advisory Board and our Vice President of Education. The webinars stress several important themes, including: encouraging users to discuss information with medical experts, avoiding dispensing of personal or medical advice, and maintaining a non-judgmental perspective.

We have 104 trained peer navigators, both male and female, ranging in age from 21 – 73. Both cancer survivors, as well as high-risk individuals are represented. Peer volunteers come from diverse backgrounds and geographic locations, and have made a variety of medical decisions about genetic testing, cancer screening, chemoprevention, and risk-reducing surgeries.

The program launched in April 2016. We will present results from post-call evaluation surveys completed from April 1, 2016 through September 30, 2016. Data on most commonly requested topics, user satisfaction, ease of use, and intention to use the information in shared decision-making with their health care provider will be presented.

Citation Format: Rezende LF, Cohen S, Rose D, Friedman SJ. Peer navigation for people affected by hereditary breast, ovarian and related cancers: Results from the first six months [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-18-02.

Costs of the police service and mental healthcare pathways experienced by individuals with enduring mental health needs

BACKGROUND

Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.

AIMS

To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.

METHOD

Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.

RESULTS

Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between -8% and +6%.

CONCLUSIONS

Recommended enhancements to care pathways only marginally increase individual-level costs.

Cognitive-behaviour therapy for post-traumatic stress in schizophrenia. A randomized controlled trial

BACKGROUND

There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia.

METHOD

A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive-behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale.

RESULTS

Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes.

CONCLUSIONS

The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.

Location of care for people with serious mental illness (LOCAPE): implications for service use and costs using a mixed-methods approach

Background

This study focuses on health care received by people with serious mental illness (SMI). The aim is to examine the economic implications of different locations of management of care and the views of service users and staff regarding services set up as alternatives to secondary care.

Objectives

Specific objectives are to (1) identify people with SMI managed in primary or secondary care; (2) identify those who could be potentially transferred to primary care; (3) compare the characteristics of these groups; (4) compare service use and costs; (5) generate models to estimate cost changes following transfer between settings; (6) identify characteristics associated with time to transition to secondary care; (7) investigate experiences of patients receiving support from community-based interventions; and (8) assess the economic impact of interventions to facilitate transfer of care management.

Methods

(1) Quantitative component – using linked primary and secondary care data we examined differences between those discharged to primary care (n = 1410) and those still in secondary care (n = 1629). Service use and costs were compared and predictors of costs were identified using regression models. (2) Qualitative component – interviews following a topic guide were conducted at two time points with 31 people using and 10 people working in services set up as alternatives to secondary care. (3) Economic modelling – an analysis of the health-care costs of the above services compared with usual care was conducted using decision modelling. Data were obtained from local services where possible, and the time horizon was 12 months.

Results

(1) Quantitative component – characteristics of those discharged to primary care (n = 1410) were similar to those still in secondary care (n = 1629). Costs for those discharged to primary care were 48% lower than for those remaining in secondary care. Other variables strongly associated with costs were a history of violence and a diagnosis of schizophrenia or bipolar disorder. Few patients in secondary care had a high probability of primary care management and, therefore, excess costs were only around £150,000 across the sample. (2) Qualitative component – service users’ views about a community options team and a primary care support service were positive and compared favourably to services used previously. Views about peer support were slightly less consistent. Staff had concerns with regard to caseload sizes and staff turnover. (3) Economic modelling – services to help transition had costs that were 40% of those for standard care. The results of this showed that triaging patients into these services would save £1578 over a 1-year period and that the results were robust to changes in most parameters.

Limitations

Analysis was hindered by the extent to which data were available. Qualitative analyses were limited by the fact that most of the participants did not have a SMI as usually defined and that many had been out of contact with secondary services for a long period of time.

Conclusions

Costs are substantially lower in primary care than secondary care, even after controlling for service-user patient differences. Generally, there is satisfaction with services to help facilitate primary care provision and these appear to be cost saving. Future work should continue the analysis of linked data and involve a more comprehensive evaluation of the specific services investigated here.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Electrochemical DNA biosensors based on long-range electron transfer: investigating the efficiency of a fluidic channel microelectrode compared to an ultramicroelectrode in a two-electrode setup

Here, we describe the transposition of an ultramicroelectrode (UME) setup into a microfluidic chip configuration for DNA biosensors. The hydrodynamic properties of the fluidic channel microelectrode were screened with an [Fe(iii)(CN)₆]^3-/[Fe(ii)(CN)₆]^4- redox couple by cyclic voltammetry to provide a basis for further biological processes. A 23-base DNA probe was self-assembled into a monolayer on gold microelectrodes both in classical configuration and integrated in a microfluidic setup. Special interest was focused on the DNA target mimicking the liver-specific micro-ribonucleic acid 122 (miRNA122). Long-range electron transfer was chosen for transducing the hybridization. This direct transduction was indeed significantly enhanced after hybridization due to DNA-duplex π-stacking and the use of redox methylene blue as a DNA intercalator. Quantification of the target was deduced from the resulting electrical signal characterized by cyclic voltammetry. The limit of detection for DNA hybridization was 0.1 fM in stopped flow experiments, where it can reach 1 aM over a 0.5 μL s^-1 flow rate, a value 10⁴-fold lower than the one measured with a conventional UME dipped into an electrolyte droplet under the same analytical conditions. An explanation was that forced convection drives more biomolecules to the area of detection even if a balance between the speed of collection and the number of biomolecules collected has been found. The latter point is discussed here along with an attempt to explain why the sensor has reached such an unexpected value for the limit of detection.