Role of clinical attachments in psychiatry for international medical graduates to enhance recruitment and retention in the NHS.

AIMS AND METHOD: There are numerous challenges in the recruitment and retention of the medical workforce in psychiatry. This mixed-methods study examined the role of psychiatry clinical attachments for international medical graduates (IMGs) to enhance recruitment and retention. An online survey was launched to capture views and perceptions of IMGs about clinical attachments. The quantitative and qualitative responses were analysed to elicit findings. RESULTS: In total, 92 responses were received, with respondents commonly from India, Pakistan and Egypt. Respondents were mostly aged 25-34, with ≥3 years of psychiatry experience. Over 80% expressed strong interest in completing a psychiatry clinical attachment and believed it would support career progression. Qualitative data indicated that IMGs hoped to gain clinical experience and understanding of the National Health Service (NHS). They wished for a clearer, simpler process for clinical attachments. CLINICAL IMPLICATIONS: Clinical attachment can be mutually beneficial, providing IMGs with opportunity to confidently start their psychiatry career in the UK and enhance medical recruitment in mental health services across the NHS.

Is it 'just' trauma? Use of trauma-informed approaches and multi-agency consultation in mental healthcare of looked after children.

This article presents three case studies of patients that a child and adolescent mental health service (CAMHS) have supported and its purpose is to encourage discussion of two key learning points. The first of these is the utility of developmental trauma as an approach for children with mental health presentations. The second centres on the importance of multi-agency working when working with young people, principally those within the UK's local authority care system ('looked after children'), who have had traumatic experiences in order to enhance positive outcomes. We also want to encourage consideration of the implications of developmental trauma for current core CAMHS therapeutic models in an attempt to reach beyond the often held narrative that the trauma formulation implies there is 'just trauma, no mental illness'.

How effective is group intervention in the treatment for unaccompanied and accompanied refugee minors with mental health difficulties: A systematic review.

BACKGROUND: Unaccompanied refugee minors (URM) are at significantly higher risk of trauma exposure and mental illness. Research examining the most effective treatments for this population is limited. AIMS: To study the available research evidence on outcomes from various group interventions in this population. The objective is to investigate if these can be used clinically in future interventions. METHODS: Systematic review was carried out for patient outcomes where group therapy was used as treatment in URM. Studies with ARM (Accompanied refugee minors) were included because of similarities between these groups and because many studies were mixed population. RESULTS: Seventeen papers met eligibility criteria with a total of N = 1,119 participants. About 80% studies with a quantitative component reported improvements, and 69% of the studies that carried out statistical analyses reported statistically significant improvements in mental health symptoms. Every qualitative measure reported positive outcome for the participants. Studies with URM tended to show improved outcomes more often than studies exclusively with ARM. CONCLUSIONS: The evidence demonstrates the efficacy of group therapy in improving mental health outcomes, although the number of studies with robust methodology is small. Group intervention has potential to improve engagement and outcomes of URM with mental illness. Future direction for research is discussed.

Experiences and emotional strain of NHS frontline workers during the peak of the COVID-19 pandemic.

BACKGROUND: The mental health of the population has been negatively affected due to the pandemic. Frontline healthcare workers with increased exposure to COVID diagnosis, treatment and care were especially likely to report psychological burden, fear, anxiety and depression. AIM: To elicit how working as a health professional during the pandemic is impacting on the psychological wellbeing of frontline staff. METHOD: United Kingdom population of healthcare workers were approached by advertising the survey via social media, NHS trusts and other organisations. Open-ended survey answers were qualitatively explored using content analysis. RESULTS: Survey collected data from 395 NHS staff was developed into three themes; (1) Despair and uncertainty: feeling overwhelmed trying to protect everyone, (2) Behavioural and psychological impact: affecting wellbeing and functioning and (3) Coping and employer support: getting the right help. CONCLUSION: NHS staff felt enormous burden to adequately complete their professional, personal and civil responsibility to keep everyone safe leading to negative psychological and behavioural consequences and desire for NHS employers to offer better support. As the pandemic progresses, the results of this study may inform NHS employers on how optimum support can be offered to help them cope with negative psychological consequences of the pandemic.

Mental health services for children in care: investigation to elicit outcomes of direct and indirect interventions.

AIMS AND METHOD: The aim of this study was to compare the efficacy of direct therapy and indirect consultation for treating mental health difficulties among looked after children (LAC), and also to identify any demographic or clinical predictor variables for outcomes in this cohort. A retrospective evaluation of mental health outcomes for 104 LAC was conducted. All children received network consultation in combination with or without direct therapeutic work. Outcomes were compared between the groups with and without direct therapeutic intervention. RESULTS: Those receiving both treatments displayed significantly greater Strengths and Difficulties Questionnaire (SDQ)-rated improvements than those receiving just consultation. Nonetheless, improvements in scores for the latter group were significant relative to baseline. Treatment duration, younger age at referral and start SDQ were all correlated with positive outcomes, while number of address changes predicted higher start SDQ scores. CLINICAL IMPLICATIONS: Despite the retrospective design of this study, its results can be considered as preliminary findings to guide treatment decisions in LAC.

What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care.

BACKGROUND: Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful. METHOD: One hundred and twenty-six 11-21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed. RESULTS: Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful. CONCLUSION: Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning. KEY PRACTITIONER MESSAGE: Little is known about what young people who self-harm find helpful, particularly for looked-after young people. CAMHS was named amongst the most helpful and the least helpful services by both looked-after and non-looked-after young people. Social services and A&E were frequently cited amongst the least helpful sources of support. Young people report finding informal support helpful, including family and friends. There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that.

Exploring stigma and its effect on access to mental health services in unaccompanied refugee children.

Aims and methodDespite substantial evidence to show that unaccompanied refugee children suffer a high prevalence of mental illness, their access to services remains poor. One may hypothesise that this is associated with their negative perceptions of mental illness. However, there has been little research exploring this important subject. We aimed to explore unaccompanied refugee children's experiences, perceptions and beliefs of mental illness, focusing on stigma. Fifteen unaccompanied refugee children and 15 carers were interviewed by a semi-structured interview. Thematic analysis was used to analyse data. RESULTS: Three main themes were identified, focusing mainly on issues of stigma related to mental health, mental illness and their treatment, and they were interpreted in detail.Clinical implicationsOur findings will contribute to current understanding of stigma and discrimination, and their effect on service engagement, and will hopefully stimulate interest to further explore this area and develop potential solutions.Declaration of interestNone.

Potential barriers in the therapeutic relationship in unaccompanied refugee minors in mental health.

Background: Unaccompanied refugee minors present with disproportionately high prevalence of emotional and psychological morbidities. However, their utilization of mental health services has been shown to be significantly poorer than the indigenous population of the country they seek asylum in. Despite this, there is limited research exploring their perspectives on the barriers they face. Aims: This research aims to understand unaccompanied refugee minors' and their carers' perceptions of the barriers to utilize mental health services and to explore issues perceived to be related to poor engagement with services. Methods: Semi-structured interviews with 15 unaccompanied refugee minors and their carers were conducted. This was to elicit their views, perceptions and beliefs based on their experience of receiving treatment from a specialist mental health service in the UK. Results: Thematic analysis was used and the findings were categorised into two broad themes; the participants' perceptions of the intervention and perceptions of the professionals. Salient aspects of these are discussed. Conclusions: The findings have potential to stimulate further research into gaining a better understanding of the barriers these young people face in accessing help, and may contribute to developing services that are more efficient in engaging this vulnerable group and meeting their specific needs.

An interpretative phenomenological analysis of young people's self-harm in the context of interpersonal stressors and supports: Parents, peers, and clinical services.

RATIONALE: Self-harm in young people is of significant clinical concern. Multiple psychological, social and clinical factors contribute to self-harm, but it remains a poorly understood phenomenon with limited effective treatment options. OBJECTIVE: To explore young women's experience of self-harm in the context of interpersonal stressors and supports. METHOD: Fourteen adolescent females (13-18 years) who had self-harmed in the last six months completed semi-structured interviews about self-harm and supports. Interpretative phenomenological analysis was undertaken. RESULTS: Themes identified were: 1) Arguments and worries about family breakdown; 2) Unhelpful parental response when self-harm discovered and impact on seeking support; 3) Ongoing parental support; 4) Long-term peer victimization/bullying as a backdrop to self-harm; 5) Mutual support and reactive support from friends (and instances of a lack of support); 6) Emotions shaped by others (shame, regret and feeling 'stupid to self-harm'); and 7) 'Empty promises' - feeling personally let down by clinical services. These themes were organised under two broad meta-themes (psychosocial stressors, psychosocial supports). Two additional interconnected meta-themes were identified: Difficulties talking about self-harm and distress; and Impact on help-seeking. CONCLUSION: Parents and peers play a key role in both precipitating self-harm and in supporting young people who self-harm. The identified themes, and the apparent inter-relationships between them, illustrate the complexity of self-harm experienced in the context of interpersonal difficulties, supports, and emotions. These results have implications for improving support from both informal and clinical sources.

A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care.

OBJECTIVES: Young people in the public care system ('looked-after' young people) have high levels of self-harm. DESIGN: This paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS). METHODS: Young people in care (looked-after group: n = 24; 14-21 years) and young people who had never been in care (contrast group: n = 21; 13-21 years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6 months. RESULTS: Young people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6 months prior to most recent self-harm. CONCLUSIONS: Sequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended. PRACTITIONER POINTS: Self-harm (and factors associated with self-harm) can change and evolve over time; assessments need to reflect this. Looked-after young people reported feeling better after first self-harm; fearlessness of death, access to means, and impulsivity were reported as key in recent self-harm. Underlying emotional distress, particularly depression and self-hatred were important in both first and most recent self-harm. Looked-after young people should undergo regular monitoring and assessment of each self-harm episode and access to potentially fatal means should be restricted. The CaTS would have clinical utility as an assessment tool Recruiting participants can be a significant challenge in studies with looked-after children and young people. Future research with larger clinical samples would be valuable.

An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults.

Six young adults (aged 19-21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.

The views and opinions of CAMHS professionals on their role and the role of others in attending to children who self-harm.

Self-harm in young people is a common presentation to mental health services. There is little literature, however, on how professionals view their role and the role of others within the assessment of these young people, and the relative accountability. This study explored Child and Adolescent Mental Health Services (CAMHS) professionals' views of these roles utilising a qualitative framework. The interviews of 18 CAMHS professionals from different disciplines were analysed using a thematic approach. Findings showed participants to be clear regarding the remit of their own role and the purpose of the assessment process, but were less confident in the abilities of those outside their service. They commented on the ongoing problems of stigma in this area and the difficulties with multi-agency working. Findings suggested possible ways to ameliorate these problems; however, the current economic climate may not be conducive to this.

'This doctor, I not trust him, I'm not safe': the perceptions of mental health and services by unaccompanied refugee adolescents.

BACKGROUND: Unaccompanied refugee adolescents are a small but clinically significant group. This group is vulnerable with physical and psychiatric needs which are often not met. There are several barriers to providing care for this group, originating with the refugees but also due to service provision. AIMS: The aim of this research is to appreciate the views and perceptions that unaccompanied minors hold about mental health and services. METHOD: Fifteen unaccompanied adolescents engaged with mental health services were interviewed, and thematic analysis was employed to explore relevant issues. DISCUSSION: Their views reflected a range of opinions on mental health and the treatments they received, but many held negative attitudes toward mental health and had a lack of trust in services. This could be explained by their descriptions of their experiences within their home country of psychiatric care, their experiences of being a refugee/asylum-seeker or cultural differences. CONCLUSION: We argue it is important to engage this group in the development of policy and practice in child mental health, and in developing services.

Relationship of psychosocial adversity to depressive symptoms and self-harm in young homeless people.

An increased incidence of psychiatric disorders has been reported in homeless young people. These disorders are often related to their childhood experience of trauma, although less is known about how secondary traumatic experiences while being homeless affect psychopathology. The aim of this study was to establish the relationship between life adversities - living on the street, physical and sexual abuse (during both childhood and young adult life) and substance misuse - and depressive symptoms and self-harm among homeless young people.

Clinical profile and outcome of conversion disorder in children in a tertiary hospital of north India.

The clinical profile, commonly involved precipitating factors, comorbid conditions, treatment options and outcome of conversion disorder in 40 children in a tertiary level hospital in North India were studied, retrospectively. Majority of the patients were from rural India. Most common presenting symptom was psychogenic non-epileptic seizures; depression and anxiety were among the commonest comorbid conditions. Precipitating factors were predominantly scholastic problems. Treatment option included either psychotherapy only or combination of psychotherapy and pharmacotherapy. No significant difference was found in terms of outcome between the in-patient and out-patient treatment groups. This observation could be cost effective for developing countries like India, where the resources are very limited.