How do recorded mental health recovery narratives create connection and improve hopefulness?

BACKGROUND: Mental health recovery narratives are an active ingredient of recovery-oriented interventions such as peer support. Recovery narratives can create connection and hope, but there is limited evidence on the predictors of impact. AIMS: The aim of this study was to identify characteristics of the narrator, narrative content and participant which predict the short-term impact of recovery narratives on participants. METHOD: Independent studies were conducted in an experimental (n = 40) and a clinical setting (n = 13). In both studies, participants with mental health problems received recorded recovery narratives and rated impact on hopefulness and connection. Predictive characteristics were identified using multi-level modelling. RESULTS: The experimental study found that narratives portraying a narrator as living well with mental health problems that is intermediate between no and full recovery, generated higher self-rated levels of hopefulness. Participants from ethnic minority backgrounds had lower levels of connection with narrators compared to participants from a white background, potentially due to reduced visibility of a narrator's diversity characteristics. CONCLUSIONS: Narratives describing partial but not complete recovery and matching on ethnicity may lead to a higher impact. Having access to narratives portraying a range of narrator characteristics to maximise the possibility of a beneficial impact on connection and hopefulness.

'A limpet on a ship': Spatio-temporal dynamics of patient and public involvement in research.

OBJECTIVE: To understand how current funding expectations that applied health research is undertaken in partnership with research institutions, health service providers and other stakeholders may impact on patient and public involvement (PPI). BACKGROUND: While there is considerable research on the potential impact of PPI in health research, the processes of embedding PPI in research teams remain understudied. We draw on anthropological research on meetings as sites of production and reproduction of institutional cultures and external contexts to investigate how these functions of meetings may affect the potential contributions of patients, carers and the public in research. METHODS: We present an ethnography of meetings that draws from a larger set of case studies of PPI in applied health research settings. The study draws on ethnographic observations, interviews with team members, analysis of documents and a presentation of preliminary findings through which feedback from informants was gathered. RESULTS: We identified four means by which the oversight meetings regulated research and constrained the possibilities for PPI: a logic of 'deliverables' and imagined interlocutors, the performance of inclusion, positioning PPI in an 'elsewhere' of research, and the use of meetings to embed apprenticeship for junior researchers. CONCLUSIONS: PPI is essentially out of sync from the institutional logic of 'deliverables' constituting research partnerships. Embedding PPI in research requires challenging this logic.

Estranged relations: coercion and care in narratives of supported decision-making in mental healthcare.

Supported decision-making has become popular among policymakers and mental health advocates as a means of reducing coercion in mental healthcare. Nevertheless, users of psychiatric services often seem equivocal about the value of supported decision-making initiatives. In this paper we explore why such initiatives might be rejected or ignored by the would-be beneficiaries, and we reflect on broader implications for care and coercion. We take a critical medical humanities approach, particularly through the lens of entanglement. We analyse the narratives of 29 people diagnosed with mental illness, and 29 self-identified carers speaking of their experiences of an Australian mental healthcare system and of their views of supported decision-making. As a scaffolding for our critique we consider two supported decision-making instruments in the 2014 Victorian Mental Health Act: the advance statement and the nominated person. These instruments presuppose that patients and carers endorse a particular set of relationships between the agentic self and illness, as well as between patient, carer and the healthcare system. Our participant narratives instead conveyed 'entangled' relations, which we explore in three sections. In the first we show how ideas about fault and illness often coexisted, which corresponded with shifting views on the need for more versus less agency for patients. In the second section, we illustrate how family carers struggled to embody the supported decision-making ideal of the independent yet altruistic nominated person, and in the final section we suggest that both care and coercion were narrated as existing across informal/formal care divisions. We conclude by reflecting on how these dynamic relations complicate supported decision-making projects, and prompt a rethink of how care and coercion unfold in contemporary mental healthcare.

Epidemic Time: Thinking from the Sickbed.

To experience an epidemic while lying on a sickbed opens up other ways of thinking through time, epidemics, and sequence from those developed by Charles Rosenberg in his 1989 essay, "What Is an Epidemic?". In this essay, a patient recovering from COVID-19 analyzes how histories of epidemics often follow the logic proposed by the discipline of epidemiology itself: a focus on acute cases and on a tracking of the "peak(s)" often means that longer temporalities of suffering are hidden. In contrast, this essay follows "Long Covid"-an illness collectively made and named by patients, which changed how the natural history of a new disease (COVID-19) was being mapped out by conventional scientific experts. Long Covid conceptualizes time differently from common categories and prefixes used in medicine and epidemiology, such as the "chronic" or the "post-." The collective labor of ill people thinking from the sickbed-both those with Long Covid and those working to bring to visibility other illnesses and the sequelae of other epidemics-has allowed other possible arrangements of sick bodies, symptoms, and diagnostic classifications to come into view. These arrangements hold potential for historians of medicine, as well as for clinical scientists.

The side effects of service changes: exploring the longitudinal impact of participation in a randomised controlled trial (DOORWAYS) on staff perceptions of barriers to change.

BACKGROUND: Staff and service users have expressed concerns that service improvements in British mental health wards have been slow or transient. It is possible that certain changes are positive for some (e.g. service users), but negative for others (e.g. staff), which may affect implementation success. In this study, we explore whether a programme of change to improve the therapeutic milieu on mental health wards influenced staff perceptions of barriers to change, 12 months after implementation. METHOD: A cluster randomised controlled trial called DOORWAYS was conducted on eight British, inner-city acute mental health wards. Randomisation was achieved using a list randomly generated by a computer. A psychologist trained ward staff (mainly nurses) to deliver evidence-based groups and supported their initial implementation. The impact of these changes was measured over 12 months (when 4 wards were randomised), according to nurses' perceptions of barriers to change (VOCALISE), using unstructured multivariate linear regression models. This innovative analysis method allows maximum use of data in randomised controlled trials with reduced sample sizes due to substantial drop out rates. The contextual influences of occupational status (staff) and of workplace setting (ward) were also considered. RESULTS: Staff who participated in the intervention had significantly worse perceptions of barriers to change at follow up. The perceptions of staff in the control group did not change over time. In both groups (N = 120), direct care staff had more negative perceptions of barriers to change, and perceptions varied according to ward. Across time, direct care staff in the intervention group became more negative than those in the control group. CONCLUSION: Participation in this program of change, worsened staff perceptions of barriers to change. In addition, occupational status (being from the direct care group) had a negative effect on perceptions of barriers to change, an effect that continued across time and was worse in the intervention group. Those providing direct care should be offered extra support when changes are introduced and through the implementation process. More effort should be placed around reducing the perceived burden of innovation for staff in mental health wards. TRIAL REGISTRATION: ISRCTN, ISRCTN 06545047. Registered 29/04/2010, https://www.isrctn.com/search?q=06545047.

Corrective biology: psychosomatics in and as neuropsychoanalysis.

This article analyses how and with what consequences body-mind relations (the sphere of the psychosomatic) are being modelled in the 21st century through considering the interdiscipline of neuropsychoanalysis. The promise of the term psychosomatic lies in its efforts to rework standard, bifurcated models of mind and body: somatic acts are simultaneously psychic acts. But neuropsychoanalysis, as it brings the neurosciences and psychoanalysis together to model an embodied 'MindBrain', ends up evacuating another potent characteristic found in much of the psychosomatic tradition-its refusal to adjudicate, a priori, what counts as the adaptive or well-regulated subject. The psychosomatic problem in psychoanalysis profoundly disturbs everyday models of functionality, adaptation and agency, by positing the psyche as an 'other' of the physiological within the physiological. By contrast, neuropsychoanalysis ends up parsing too easily the healthy from the pathological body, such that it is only the latter that is subject to forces that work against self-preservation and self-regulation. In so doing, neuropsychoanalysis recasts the radical problematic that the psychosomatic installed for psychoanalysis in the direction of a corrective biology. This corrective biology is given form in two ways: (1) through translating the Freudian drive-that unruly and foundational concept which addresses the difficult articulation of soma and psyche-into a series of Basic Emotion Systems modelled by the affective neuroscientist Jaak Panksepp and (2) through resituating and quarantining the troubling, non-adaptive aspects of the Freudian psyche within the domain of addiction. That easy separation between the healthy and the pathological is all too often found in current descriptions of healthcare and patient encounters. The article refuses it and calls for the revivification of other ways of thinking about how human subjects-psychosomatic organisms-find ways to live, and to die.

The Feasibility and Acceptability to Service Users of CIRCuiTS, a Computerized Cognitive Remediation Therapy Programme for Schizophrenia.

BACKGROUND: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. AIMS: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. METHOD: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). RESULTS: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. CONCLUSIONS: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.

The Intimate Geographies of Panic Disorder: Parsing Anxiety through Psychopharmacological Dissection.

The category of panic disorder was significantly indebted to early psychopharmacological experiments (in the late 1950s and early 1960s) by the psychiatrist Donald Klein, in collaboration with Max Fink. Klein's technique of "psychopharmacological dissection" underpinned his transformation of clinical accounts of anxiety and was central in effecting the shift from agoraphobic anxiety (with its spatial imaginary of city squares and streets) to panic. This technique disaggregated the previously unitary affect of anxiety-as advanced in psychoanalytic accounts-into two physiological and phenomenological kinds. "Psychopharmacological dissection" depended on particular modes of clinical observation to assess drug action and to interpret patient behavior. The "intimate geographies" out of which panic disorder emerged comprised both the socio-spatial dynamics of observation on the psychiatric ward and Klein's use of John Bowlby's model of separation anxiety-as it played out between the dyad of infant and mother-to interpret his adult patients' affectively disordered behavior. This essay, in offering a historical geography of mid-twentieth-century anxiety and panic, emphasizes the importance of socio-spatial setting in understanding how clinical and scientific experimentation opens up new ways in which affects can be expressed, shaped, observed, and understood.

Consenting for contact? Linking electronic health records to a research register within psychosis services, a mixed method study.

BACKGROUND: Research registers of potential participants linked to Electronic Health Records (EHRs) provide a basis for screening and identifying people suitable for studies. Such a system relies upon people joining the register and giving permission for their record to be used in this way. This study describes the process of training clinicians to explain EHR-linked research registers to service users, and to recruit them onto the register. METHOD: Training materials were developed for clinicians to help them describe the register to service users. These materials were based upon findings from focus groups reported elsewhere, they were then tested with 31 clinicians in early intervention psychosis services and each clinician discussed the register with service users on their caseload (n = 100 service users). Consultations were recorded and analysed in relation to their coverage of the training criteria. Service users also provided data on the acceptability of the process from their perspective. The content of clinicians' explanations to service users was described, and then compared against the likelihood of service users joining the register. Interpretive statistics (t-test and Chi-Squared) were used to explore differences between consultations in which service users agreed to join the register, and consultations where they did not agree to join. RESULTS: Service users appeared more likely to join the register if they felt control over what they signed up to, this necessitated understanding that they could decide when, how often, and by whom they were contacted, that joining the register did not automatically enlist them to future studies, and that they could change their mind in future. Clinicians' explanations did not always include that researchers would be able to see the service users' EHR. Service users often confused the idea of signing up to the register and signing up to studies themselves. Confidentiality was not well explained, but service users were not always concerned by confidentiality. CONCLUSION: EHR-linked research registers provide recruitment opportunities, and help service users to find out about research. Implementing these registers within mental health settings requires a trained clinical workforce and an informed service user population.

Critical medical humanities: embracing entanglement, taking risks.

What can the medical humanities achieve? This paper does not seek to define what is meant by the medical humanities, nor to adjudicate the exact disciplinary or interdisciplinary knowledges it should offer, but rather to consider what it might be capable of doing. Exploring the many valences of the word 'critical', we argue here for a critical medical humanities characterised by: (i) a widening of the sites and scales of 'the medical' beyond the primal scene of the clinical encounter; (ii) greater attention not simply to the context and experience of health and illness, but to their constitution at multiple levels; (iii) closer engagement with critical theory, queer and disability studies, activist politics and other allied fields; (iv) recognition that the arts, humanities and social sciences are best viewed not as in service or in opposition to the clinical and life sciences, but as productively entangled with a 'biomedical culture'; and, following on from this, (v) robust commitment to new forms of interdisciplinary and cross-sector collaboration. We go on to introduce the five other articles published in this special issue of the journal, reflecting on the ways in which collaboration and critique are articulated in their analyses of immunology, critical neuroscience, toxicity, global clinical labour, and psychological coercion and workfare. As these articles demonstrate, embracing the complex role of critical collaborator--one based on notions of entanglement, rather than servility or antagonism--will, we suggest, develop the imaginative and creative heterodox qualities and practices which have long been recognised as core strengths of the medical humanities.

Social Science and Neuroscience beyond Interdisciplinarity: Experimental Entanglements.

This article is an account of the dynamics of interaction across the social sciences and neurosciences. Against an arid rhetoric of 'interdisciplinarity', it calls for a more expansive imaginary of what experiment - as practice and ethos - might offer in this space. Arguing that opportunities for collaboration between social scientists and neuroscientists need to be taken seriously, the article situates itself against existing conceptualizations of these dynamics, grouping them under three rubrics: 'critique', 'ebullience' and 'interaction'. Despite their differences, each insists on a distinction between sociocultural and neurobiological knowledge, or does not show how a more entangled field might be realized. The article links this absence to the 'regime of the inter-', an ethic of interdisciplinarity that guides interaction between disciplines on the understanding of their pre-existing separateness. The argument of the paper is thus twofold: (1) that, contra the 'regime of the inter-', it is no longer practicable to maintain a hygienic separation between sociocultural webs and neurobiological architecture; (2) that the cognitive neuroscientific experiment, as a space of epistemological and ontological excess, offers an opportunity to researchers, from all disciplines, to explore and register this realization.

Psychiatric diagnosis: the indispensability of ambivalence.

The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatric diagnosis over others, as well as to polarise positions regarding psychiatric diagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatric diagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and spatially complex, as well as highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatric diagnosis in order to emphasise the conceptual-and potentially ethical-benefits of ambivalence vis-à-vis the achievements and problems of psychiatric diagnosis.

Geopsychiatry and geography: A response.

BACKGROUND: This contribution responds to three articles (we refer to all three as 'editorials') concerning something called 'geopsychiatry'. AIMS: To evaluate claims made in these editorials for 'geopsychiatry' as a new field of inquiry at the interface between geography and psychiatry. METHOD: Close critical reading of two editorials in the International Journal of Social Psychiatry - entitled 'Geographical determinants of mental health' and 'Political determinants of mental health' - and one in the International Review of Psychiatry - entitled 'What is geopsychiatry?' RESULTS: While this geopsychiatry initiative is to be applauded, disquiet can be expressed about the almost complete neglect of a pre-existing domain of inquiry - 'mental health geography' or 'the geography of mental health' - that has long been researched by academic geographers and cognate scholars. Key trajectories in this field can be identified and related to the proposed foci for geopsychiatry. CONCLUSIONS: The hope is voiced that future developments in geopsychiatry will proceed in dialogue with the literature and practitioners of mental health geography.

Effectiveness and cost-effectiveness of online recorded recovery narratives in improving quality of life for people with non-psychotic mental health problems: a pragmatic randomized controlled trial.

Narratives describing first-hand experiences of recovery from mental health problems are widely available. Emerging evidence suggests that engaging with mental health recovery narratives can benefit people experiencing mental health problems, but no randomized controlled trial has been conducted as yet. We developed the Narrative Experiences Online (NEON) Intervention, a web application providing self-guided and recommender systems access to a collection of recorded mental health recovery narratives (n=659). We investigated whether NEON Intervention access benefited adults experiencing non-psychotic mental health problems by conducting a pragmatic parallel-group randomized trial, with usual care as control condition. The primary endpoint was quality of life at week 52 assessed by the Manchester Short Assessment (MANSA). Secondary outcomes were psychological distress, hope, self-efficacy, and meaning in life at week 52. Between March 9, 2020 and March 26, 2021, we recruited 1,023 participants from across England (the target based on power analysis was 994), of whom 827 (80.8%) identified as White British, 811 (79.3%) were female, 586 (57.3%) were employed, and 272 (26.6%) were unemployed. Their mean age was 38.4±13.6 years. Mood and/or anxiety disorders (N=626, 61.2%) and stress-related disorders (N=152, 14.9%) were the most common mental health problems. At week 52, our intention-to-treat analysis found a significant baseline-adjusted difference of 0.13 (95% CI: 0.01-0.26, p=0.041) in the MANSA score between the intervention and control groups, corresponding to a mean change of 1.56 scale points per participant, which indicates that the intervention increased quality of life. We also detected a significant baseline-adjusted difference of 0.22 (95% CI: 0.05-0.40, p=0.014) between the groups in the score on the "presence of meaning" subscale of the Meaning in Life Questionnaire, corresponding to a mean change of 1.1 scale points per participant. We found an incremental gain of 0.0142 quality-adjusted life years (QALYs) (95% credible interval: 0.0059 to 0.0226) and a £178 incremental increase in cost (95% credible interval: -£154 to £455) per participant, generating an incremental cost-effectiveness ratio of £12,526 per QALY compared with usual care. This was lower than the £20,000 per QALY threshold used by the National Health Service in England, indicating that the intervention would be a cost-effective use of health service resources. In the subgroup analysis including participants who had used specialist mental health services at baseline, the intervention both reduced cost (-£98, 95% credible interval: -£606 to £309) and improved QALYs (0.0165, 95% credible interval: 0.0057 to 0.0273) per participant as compared to usual care. We conclude that the NEON Intervention is an effective and cost-effective new intervention for people experiencing non-psychotic mental health problems.

Development and evaluation of a de-identification procedure for a case register sourced from mental health electronic records.

BACKGROUND: Electronic health records (EHRs) provide enormous potential for health research but also present data governance challenges. Ensuring de-identification is a pre-requisite for use of EHR data without prior consent. The South London and Maudsley NHS Trust (SLaM), one of the largest secondary mental healthcare providers in Europe, has developed, from its EHRs, a de-identified psychiatric case register, the Clinical Record Interactive Search (CRIS), for secondary research. METHODS: We describe development, implementation and evaluation of a bespoke de-identification algorithm used to create the register. It is designed to create dictionaries using patient identifiers (PIs) entered into dedicated source fields and then identify, match and mask them (with ZZZZZ) when they appear in medical texts. We deemed this approach would be effective, given high coverage of PI in the dedicated fields and the effectiveness of the masking combined with elements of a security model. We conducted two separate performance tests i) to test performance of the algorithm in masking individual true PIs entered in dedicated fields and then found in text (using 500 patient notes) and ii) to compare the performance of the CRIS pattern matching algorithm with a machine learning algorithm, called the MITRE Identification Scrubber Toolkit - MIST (using 70 patient notes - 50 notes to train, 20 notes to test on). We also report any incidences of potential breaches, defined by occurrences of 3 or more true or apparent PIs in the same patient's notes (and in an additional set of longitudinal notes for 50 patients); and we consider the possibility of inferring information despite de-identification. RESULTS: True PIs were masked with 98.8% precision and 97.6% recall. As anticipated, potential PIs did appear, owing to misspellings entered within the EHRs. We found one potential breach. In a separate performance test, with a different set of notes, CRIS yielded 100% precision and 88.5% recall, while MIST yielded a 95.1% and 78.1%, respectively. We discuss how we overcome the realistic possibility - albeit of low probability - of potential breaches through implementation of the security model. CONCLUSION: CRIS is a de-identified psychiatric database sourced from EHRs, which protects patient anonymity and maximises data available for research. CRIS demonstrates the advantage of combining an effective de-identification algorithm with a carefully designed security model. The paper advances much needed discussion of EHR de-identification - particularly in relation to criteria to assess de-identification, and considering the contexts of de-identified research databases when assessing the risk of breaches of confidential patient information.

"Nothing's changed, baby": How the mental health narratives of people with multiple and complex needs disrupt the recovery framework.

The dominant narrative in mental health policy and practice has shifted in the 21st century from one of chronic ill health to a 'recovery' orientation. Knowledge of recovery is based on narratives of people with lived experience of mental distress. However the narratives of people experiencing structural inequalities are under-represented in recovery research. Meanwhile, uses of recovery narratives have been critiqued by survivor-researchers as a co-option of lived experience to serve neoliberal agendas. To address these twin concerns, we undertook a performative narrative analysis of two 'recovery narratives' of people with multiple and complex needs, analysing their co-construction at immediate/micro and structural/macro levels. We found two contrasting responses to the invitation to tell a recovery story: a narrative of personal lack and a narrative of resistance. We demonstrate through reflexive worked examples how the genre of recovery narrative, focused on personal transformation, may function to occlude structural causes of mental distress and reinforce personal responsibility in the face of unchanging living conditions. We conclude that unacknowledged epistemological assumptions may contribute to co-constructing individualist accounts of recovery. A critical, reflexive approach, together with transparent researcher positionality, is imperative to avoid the epistemic injustice of a decontextualised form of recovery narrative.

Close to the bench as well as at the bedside: involving service users in all phases of translational research.

AIM: The paper aims to develop a model of translational research in which service user and other stakeholder involvement are central to each phase. BACKGROUND: 'Translational' is the current medical buzzword: translational research has been termed 'bench to bedside' research and promises to fast-track biomedical advances in the service of patient benefit. Models usually conceive of translational research as a 'pipeline' that is divided into phases: the early phase is characterized as the province of basic scientists and laboratory-based clinical researchers; the later phases focus on the implementation, dissemination and diffusion of health applications. If service user involvement is mentioned, it is usually restricted to these later phases. METHODS: The paper critically reviews existing literature on translational research and medicine. The authors develop a theoretical argument that addresses why a reconceptualization of translational research is required on scientific, ethical and pragmatic grounds. RESULTS: The authors reconceptualize the model of translational research as an interlocking loop rather than as a pipeline, one in which service user and other stakeholder involvement feed into each of its elements. The authors demonstrate that for the 'interlocking loop' model of translational research to be materialized in practice will require changes in how health research is structured and organized. CONCLUSION: The authors demonstrate the scientific, ethical and pragmatic benefits of involving service users in every phase of translational research. The authors' reconceptualized model of translational research contributes to theoretical and policy debates regarding both translational research and service user involvement.

The mental health strategy for Europe: why service user leadership in research is indispensable.

Recent European mental health strategies and programmes declare service user involvement to be essential in the development and evaluation of policy and services. In light of the announcement in March 2011 by the World Health Organization Regional Office for Europe of a forthcoming new mental health strategy for Europe, we propose that service user leadership in research is the most effective way of enhancing such involvement and consider what is required to broaden initiatives across Europe.

Material and epistemic precarity: It's time to talk about labour exploitation in mental health research.

The conditions under which people labour in mental health research affect how and what knowledge is produced - and who benefits or doesn't from involvement in health research systems. There has been, however, little sustained investigation of the uneven modalities of labour exploitation across what are increasingly financialised systems of mental health research. This theoretical paper advances conceptual and empirical investigations of labour in health research - outlining how material precarity and epistemic precarity often go hand in hand, and largely drawing on examples from the UK. The intertwining of labour relations and epistemic cultures can be understood by bringing together insights from two bodies of knowledge not commonly in contact with one another - survivor/service user research and critical research on universities and academic labour. The article addresses how mental health research makes significant use of the labour of (i) contract researchers (many of whom work on precarious and exploitative contracts); (ii) lay contributors (through 'patient and public involvement'); and (iii) research participants (where the conditions underpinning participation in various kinds of research increasingly blur the distinction between volunteering, and 'gig' work). Labour relations affect, and are affected by, efforts to change epistemic cultures and reduce epistemic inequalities, and epistemic and material precarity make efforts to improve research culture much more difficult. Those experiencing both material and epistemic precarity in health research systems need to be at the heart of efforts to combat both.

Rapid progress or lengthy process? Electronic personal health records in mental health.

A major objective of many healthcare providers is to increase patients' participation in their own care. The introduction of electronic personal health records (ePHRs) may help to achieve this. An ePHR is an electronic database of an individual's health information, accessible to and maintained by the patient. ePHRs are very much in vogue, with an increasing number of studies reporting their potential utility as well as cost. However, the vast majority of these studies focus on general healthcare. Little attempt has been made to document the specific problems which might occur throughout the implementation of ePHRs in mental health. This review identifies such concerns through an electronic search of the literature. Several potential difficulties are highlighted and addressed, including access to information technology, identifying relevant populations and the handling of sensitive information. Special attention is paid to the concept of 'empowerment' and what this means in relation to ePHRs.