The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Participation in leisure activities and quality of life of people with psychosis in England: a multi-site cross-sectional study.

BACKGROUND: Leisure activities can improve quality of life in the general population. For people with psychosis, negative symptoms (e.g. being unmotivated, difficulty in sticking with activities) are often a barrier to engaging in social leisure activities. However, we do not know if participation in leisure activities is associated with quality of life in this group and, whether psychosocial interventions should aim to increase leisure activities. AIM: This study investigates participation in social leisure activities of people with psychosis and whether their participation is associated with better quality of life. METHODS: A cross-sectional survey was conducted in 6 NHS mental health trusts. Adults aged 18-65 (N = 533) with a diagnosis of a psychosis-related condition (ICD-10 F20-29) were recruited from outpatient secondary mental health services. Several measures were used including an adapted version of the Time Use Survey (TUS), the Social contacts assessment (SCA) and Manchester Short Assessment of Quality of Life (MANSA). A Structural Equation Model (SEM) was used to explore the relationships between participation in leisure activities and quality of life, and whether social contacts mediated the link. RESULTS: Participants attended an average of 2.42 (SD = 1.47) leisure activities in the last 7 days. Their quality of life increased with the number of leisure activities they attended. Participation in leisure activities was positively associated with quality of life in people with psychosis (B = 0.104, SE = 0.051, p = 0.042, 95% CI [0.003 to 0.204]). Leisure activities predicted social contacts, but the link between social contacts and the quality of life was not significant. After controlling for sociodemographic factors, being female and unemployed were negatively linked with quality of life (B = - 0.101, SE = 0.048, p = 0.036, 95% CI [- 0.196 to - 0.006; B = - 0.207, SE = 0.050, p = 0.001, 95% CI [- 0.305 to - 0.108, respectively]. CONCLUSION: People with psychosis who attend more leisure activities have a higher quality of life. Quality of life was lower amongst female and unemployed participants who attended leisure activities. Intervention which helps improve participation in leisure activities may be beneficial for people with psychosis. Trial registration number ISRCTN15815862.

Neighbourhood characteristics and social isolation of people with psychosis: a multi-site cross-sectional study.

PURPOSE: People with psychosis are vulnerable to social isolation, which is associated with worse clinical outcomes. In general populations, people living in areas with higher population density have more social contacts, while those living in more socially deprived and fragmented areas are less satisfied with their relationships. We assessed whether and how neighbourhood factors are associated with social contacts and satisfaction with friendships for people with psychosis. METHODS: We carried out a cross-sectional study including people with psychosis aged 18-65 years in urban and rural sites in England. Population density and social deprivation and fragmentation indexes were described within Lower Level Super Output Areas (LSOA). Their associations with participants' social contacts and satisfaction with friendships were tested with negative binomial and ordinal regression models, respectively. RESULTS: We surveyed 511 participants with psychotic disorders. They had a median of two social contacts in the previous week (interquartile range [IQR] = 1-4), and rated satisfaction with friendships as 5 out of 7 (Manchester Short Assessment of Quality of Life; IQR = 4-6). Higher population density was associated with fewer social contacts (Z-standardised relative risk [RR] = 0.88; 95% CI = 0.79-0.99, p = 0.03), but not with satisfaction with friendships (RR = 1.08; 95% CI = 0.93-1.26, p = 0.31). No associations were found for social contacts or satisfaction with friendships with social deprivation or fragmentation indexes. CONCLUSIONS: Clinicians in urban areas should be aware that their patients with psychosis are more socially isolated when more people live around them, and this could impact their clinical outcomes. These findings may inform housing programmes.

Persuasion or coercion? An empirical ethics analysis about the use of influence strategies in mental health community care.

BACKGROUND: Influence strategies such as persuasion and interpersonal leverage are used in mental health care to influence patient behaviour and improve treatment adherence. One ethical concern about using such strategies is that they may constitute coercive behaviour ("informal coercion") and negatively impact patient satisfaction and the quality of care. However, some influence strategies may affect patients' perceptions, so an umbrella definition of "informal coercion" may be unsatisfactory. Furthermore, previous research indicates that professionals also perceive dissonance between theoretical explanations of informal coercion and their behaviours in clinical practice. This study analysed mental health professionals' (MHPs) views and the perceived ethical implications of influence strategies in community care. METHODS: Qualitative secondary data analysis of a focus group study was used to explore the conflict between theoretical definitions and MHPs' experiences concerning the coerciveness of influence strategies. Thirty-six focus groups were conducted in the main study, with 227 MHPs from nine countries participating. RESULTS: The findings indicate that not all the influence strategies discussed with participants can be defined as "informal coercion", but they become coercive when they imply the use of a lever, have the format of a conditional offer and when the therapeutic proposal is not a patient's free choice but is driven by professionals. MHPs are rarely aware of these tensions within their everyday practice; consequently, it is possible that coercive practices are inadvertently being used, with no standard regarding their application. Our findings suggest that levers and the type of leverage used in communications with the patient are also relevant to differentiating leveraged and non-leveraged influence. CONCLUSION: Our findings may help mental health professionals working in community care to identify and discuss influence strategies that may lead to unintended coercive practices.

Social Isolation and Psychosis: Perspectives from People with Psychosis, Family Caregivers and Mental Health Professionals.

This paper explores the subjective experiences of mental health practitioners, people with psychosis and carers, on social isolation and community integration of people with psychosis. Focus groups and one-to-one interviews with 80 adult participants across three sites in the UK were conducted. Audio recordings were transcribed and analysed using thematic analysis. Participants commented on various aspects that may cause social isolation or enable community integration, including institutional factors (lack of resources, hospitalisation impact), illness symptoms (e.g., paranoia; over-pathologising vs individual choice), stigma (particularly the psychosis label), and the importance of communities that foster agency and embrace change. Hospitalisation maybe be a cause for isolation and psychiatric wards should consider allowing for socialisation as a therapeutic tool. Initiatives should consider the social fabric of our communities, socioeconomic inequalities and stigmatisation. Building communities that are accepting, kind and flexible can create opportunities that could lead to independence from mental health services.

Social contacts, friends and satisfaction with friendships in patients with psychotic, mood and neurotic disorders 1 year after hospitalisation: data from five European countries.

BACKGROUND: People with severe mental illness often struggle with social relationships, but differences among diagnostic groups are unclear. We assessed and compared objective and subjective social relationship indicators among patients with psychotic, mood and neurotic disorders one year after hospitalisation in five European countries (Belgium, Germany, Italy, Poland and United Kingdom). METHODS: The number of social contacts, including family members and friends during the previous week (Social Network Schedule), and satisfaction with the number and quality of friendships (Manchester Short Assessment of Quality of Life Quality) were assessed by face-to-face interview. Linear regression models were used to analyse associations with diagnostic groups. RESULTS: Participants (n = 2155) reported on average 2.79 ± 2.37 social contacts overall in the previous week, among whom, a mean of 1.65 ± 1.83 (59.2 ± 38.7%) were friends. Satisfaction with friendships was moderate (mean 4.62, SD 1.77). In the univariable model, patients with psychotic disorders reported having less social contact with friends than those with either mood (p < 0.05) or neurotic disorders (p < 0.001), but this difference disappeared when adjusting for socioeconomic and clinical variables (ß = - 0.106, 95% CI - 0.273 to 0.061, p = 0.215). Satisfaction with friendships was similar across diagnostic groups in both univariable (ß = - 0.066, 95% CI - 0.222 to 0.090, p = 0.408) and multivariable models (ß = 0.067, 95% CI - 0.096 to 0.229, p = 0.421). The two indicators showed a weak correlation in the total sample (total social contacts, rs = 0.266; p < 0.001; friends, rs = 0.326, p < 0.001). CONCLUSION: While objective and subjective social relationship indicators appear to be weakly correlated concepts, there is no variation in either indicator across diagnostic groups when confounders are taken into account among patients with severe mental illness. Interventions specifically targeting social relationships are needed, but they do not necessitate diagnosis-specific adaptations.

Do outcomes of psychiatric hospital treatment differ for migrants and non-migrants?

PURPOSE: Providing effective treatment for immigrants is an increasing challenge for mental health services across Europe. Yet, little is known as to whether current practice is associated with different outcomes in migrant and non-migrant patients. We compared outcomes of inpatient psychiatric treatment for migrants and non-migrants in a sample from five European countries. METHODS: Patients with psychotic disorders, affective disorders or anxiety/somatisation disorders admitted to routine psychiatric inpatient treatment were assessed in hospitals in Belgium, Germany, Italy, Poland and the United Kingdom. Treatment outcomes were satisfaction with care during hospitalisation, length of stay, readmission to hospital (any and, specifically, involuntary re-hospitalisation), as well as untoward incidents in a 1-year follow-up period. Outcomes were compared between patients born inside (non-migrants) and outside (migrants) the country of treatment, through mixed regression models. RESULTS: Across all sites, 985 migrant patients and 6298 non-migrant patients were included. After accounting for the influence of confounding patient characteristics, migrants reported significantly lower treatment satisfaction, but there were no significant differences for length of stay and re-hospitalisations, in general and involuntary ones. Migrants had a lower rate of suicide attempts, but there was no significant difference in other types of untoward incidents in the year following the index admission. CONCLUSION: The study suggests that migrants are less satisfied with their hospital treatment, there is no evidence that routine inpatient care as currently provided results overall in poorer objective outcomes for migrants than in non-migrant populations.

Prevalence of and risk factors for mental disorders in refugees.

Given the increasing numbers of refugees worldwide, the prevalence of their mental disorders is relevant for public health. Prevalence studies show that, in the first years of resettlement, only post-traumatic stress disorder (PTSD) rates are clearly higher in refugees than in host countries' populations. Five years after resettlement rates of depressive and anxiety disorders are also increased. Exposure to traumatic events before or during migration may explain high rates of PTSD. Evidence suggests that poor social integration and difficulties in accessing care contribute to higher rates of mental disorders in the long-term. Policy and research implications are discussed.

Factors associated with satisfaction of inpatient psychiatric care: a cross country comparison.

BACKGROUND: Patient satisfaction is a key indicator of inpatient care quality and is associated with clinical outcomes following admission. Different patient characteristics have been inconsistently linked with satisfaction. This study aims to overcome previous limitations by assessing which patient characteristics are associated with satisfaction within a large study of psychiatric inpatients conducted across five European countries. METHODS: All patients with a diagnosis of psychotic (F2), affective (F3) or anxiety/somataform (F4) disorder admitted to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and the UK were included. Data were collected from medical records and face-to-face interviews, with patients approached within 2 days of admission. Satisfaction with inpatient care was measured on the Client Assessment of Treatment Scale. RESULTS: Higher satisfaction scores were associated with being older, employed, living with others, having a close friend, less severe illness and a first admission. In contrast, higher education levels, comorbid personality disorder and involuntary admission were associated with lower levels of satisfaction. Although the same patient characteristics predicted satisfaction within the five countries, there were significant differences in overall satisfaction scores across countries. Compared to other countries, patients in the UK were significantly less satisfied with their inpatient care. CONCLUSIONS: Having a better understanding of patient satisfaction may enable services to improve the quality of care provided as well as clinical outcomes for all patients. Across countries, the same patient characteristics predict satisfaction, suggesting that similar analytical frameworks can and should be used when assessing satisfaction both nationally and internationally.

Factorial structure of the Manchester Short Assessment of Quality of Life in patients with schizophrenia-spectrum disorders.

PURPOSE: Subjective quality of life is a central patient-reported outcome in schizophrenia-spectrum disorders. The Manchester Short Assessment of Quality of Life (MANSA) is an established and widely used instrument for its assessment. The present study is a secondary analysis of large schizophrenia studies and aims to establish the factorial structure of the MANSA with a rigorous two-step methodology. METHODS: A sample of 3120 patients was randomly split into two datasets; the first includes two thirds of the patients and serves as the calibration sample (N = 2071) and the second includes one third of them and serves as the validation sample (N = 1049). We performed an exploratory factor analysis with the calibration sample followed by a confirmatory factor analysis with the validation sample. RESULTS: Our results for both samples revealed a model with adequate fit comprising two factors. The first factor encompasses eight items measuring satisfaction with a variety of life and health-related aspects of quality of life, whereas the second consists of four items assessing satisfaction with living environment comprising living alone or with others, accommodation, family, and safety. These two factors correlate in a different way with socio-demographic characteristics such as age and living conditions. CONCLUSIONS: Future trials and service evaluation projects using the MANSA to measure quality of life should take into account that satisfaction with living environment may be distinct from satisfaction with other life and health-related aspects of quality of life.

Helping people with psychosis to expand their social networks: the stakeholders' views.

BACKGROUND: People with psychosis experience more social isolation than any other diagnostic group and have smaller social networks than the general population. This isolation can have a detrimental effect on quality of life. No direct, standardised interventions have been developed to specifically target this issue. Stakeholders input appears crucial in the process of developing such an intervention. This study aimed to identify the main considerations when developing an intervention aiming to reduce social isolation in people with psychosis. METHODS: Focus groups and individual interviews were conducted with patients, carers and mental health staff. Data was thematically analysed. RESULTS: Thirty four patients with psychosis, 26 carers of people experiencing psychosis and 22 mental health professionals participated in the study. Suggested aspects to be considered in a novel intervention were: i) finding and training the right staff member; ii) discussing negative social attitudes and patients' previous negative experiences, iii) addressing personal ambivalence; iv) establishing how best to provide information about social activities; v) facilitating access to social activities, vi) striking a balance between support and independence. CONCLUSION: The suggestions identified can help to develop more targeted approaches to reduce social isolation within this patient group. A patient-centred approach and generic communication skills appear to be underpinning most of the helpful elements identified, whilst specific techniques and skills can help to overcome negative past experiences and motivational barriers.

Personal continuity versus specialisation of care approaches in mental healthcare: experiences of patients and clinicians-results of the qualitative study in five European countries.

BACKGROUND: The current debate on organisation of the mental health care raises a question whether to prioritise specialisation of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding specialisation (SC) and personal continuity (PCC) of care in five European countries. METHODS: Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders (F20-49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and analysed through a thematic analysis method. RESULTS: Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic relationship and the smooth transition between hospital and community care. Many positive experiences of patients and clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treatment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for coercion, restraint, forced medication or involuntary admission within PCC. CONCLUSIONS: Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). Therefore, future reforms of mental health services should offer a free choice of either approach, considering that there is no evidence of differences in patient outcomes between PCC and SC approaches.

Use of psychiatric hospitals and social integration of patients with psychiatric disorders: a prospective cohort study in five European countries.

PURPOSE: Long lengths of stay (LoS) in psychiatric hospitals or repeated admission may affect the social integration of patients with psychiatric disorders. So far, however, studies have been inconclusive. This study aimed to analyse whether long LoS or repeated admissions in psychiatric wards were associated in different ways with changes in the social integration of patients. METHODS: Within a prospective cohort study, data were collected on 2181 patients with a main ICD-10 diagnosis of psychotic, affective, or anxiety disorder, hospitalised in the UK, Italy, Germany, Poland, and Belgium in 2015. Social integration was measured at baseline and 1 year after admission using the SIX index, which includes four dimensions: employment, housing, family situation, and friendship. Regression models were performed to test the association between LoS, the number of admissions, and the change in social integration over the study period, controlling for patients' characteristics (trial registration ISRCTN40256812). RESULTS: A longer LoS was significantly associated with a decrease in social integration (ß = - 0.23, 95%CI - 0.32 to - 0.14, p = 0.03), particularly regarding employment (OR = 2.21, 95%CI 1.18-3.24, p = 0.02), housing (OR = 3.45, 95%CI 1.74-5.16, p < 0.001), and family situation (OR = 1.94, 95%CI 1.10-2.78, p = 0.04). In contrast, repeated admissions were only associated with a decrease in friendship contacts (OR = 1.15, 95CI% 1.08-1.22, p = 0.03). CONCLUSIONS: Results suggest that a longer hospital LoS is more strongly associated with a decrease in patients' social integration than repeated admissions. Special attention should be paid to helping patients to find and retain housing and employment while hospitalised for long periods.

Mental health in hospital emergency departments: cross-sectional analysis of attendances in England 2013/2014.

OBJECTIVE: To describe the population of patients who attend emergency departments (ED) in England for mental health reasons. METHODS: Cross-sectional observational study of 6 262 602 ED attendances at NHS (National Health Service) hospitals in England between 1 April 2013 and 31 March 2014. We assessed the proportion of attendances due to psychiatric conditions. We compared patient sociodemographic and attendance characteristics for mental health and non-mental health attendances using logistic regression. RESULTS: 4.2% of ED attendances were attributable to mental health conditions (median 3.2%, IQR 2.6% to 4.1%). Those attending for mental health reasons were typically younger (76.3% were aged less than 50 years), of White British ethnicity (73.2% White British), and resident in more deprived areas (59.9% from the two most deprived Index of Multiple Deprivation quintiles (4 and 5)). Mental health attendances were more likely to occur 'out of hours' (68.0%) and at the weekend (31.3%). Almost two-thirds were brought in by ambulance. A third required admission, but around a half were discharged home. CONCLUSIONS: This is the first national study of mental health attendances at EDs in England. We provide information for those planning and providing care, to ensure that clinical resources meet the needs of this patient group, who comprise 4.2% of attendances. In particular, we highlight the need to strengthen the availability of hospital and community care 'out of hours.'

"It's a matter of building bridges " - feasibility of a carer involvement intervention for inpatients with severe mental illness.

BACKGROUND: Family and friends (carer) involvement in the treatment of people with mental illness is widely recommended. However, the implementation remains poor, especially during hospital treatment, where carers report being excluded from care decisions. METHODS: We developed structured clinical procedures to maximise carer involvement in inpatient treatment. The aim of this study was to test their feasibility across four inpatient wards in East London and explore experiences of the participants. The intervention was delivered by clinicians (social therapists, nurses and psychiatrists) who were trained by the research team. Thirty patients and thirty carers received the intervention and completed research assessments and qualitative interviews after the intervention. 80% of the patients were followed up after six weeks of admission to complete quantitative questionnaires. Six clinicians were interviewed to explore their views on the intervention. Thematic analysis was used to analyse qualitative data. RESULTS: The intervention was found to be feasible to be delivered within the first week of admission in more than a half of the patients (53%) who provided consent. The main reasons why the interventions was not delivered in the remaining 47% of patients included staff or carers not being available, withdrawal of consent from the patient or patient being discharged prior to the intervention. Two themes were identified through thematic analysis. The first captured participant experiences of the intervention as facilitating a three-way collaborative approach to treatment. The second covered how patients' mental states and practicalities of inpatient care acted as barriers and facilitators to the intervention being implemented. CONCLUSIONS: Carer involvement in hospital treatment for mental illness is more difficult to implement than is commonly thought. This study has shown that a simple structured approach can facilitate a trialogue and that patients, clinicians and carers appreciate this approach to care. Our intervention provides clear and simple manualised clinical procedures that clinicians can follow. However, even the implementation of such procedures may be challenging in the absence of wider organisational support. The involvement of senior managers and clinical leaders might play a key role in overcoming barriers and support front-line clinicians to prioritise and implement carer involvement.

Resource-oriented interventions for patients with severe mental illnesses in low- and middle-income countries: trials in Bosnia-Herzegovina, Colombia and Uganda.

BACKGROUND: Severe mental illness (SMI) presents a major burden to societies worldwide. Low- and middle-income countries (LMICs) often do not have sufficient financial resources and qualified staff to provide extensive specialised services for outpatients with SMI. Our research therefore aims to explore and test low-cost interventions that use existing resources in routine patient-clinician meetings, families and communities. METHODS: In Bosnia-Herzegovina, Colombia and Uganda, three psychosocial interventions will be tested, i.e. making patient-clinician meetings therapeutically effective through DIALOG+, family involvement in multi-family group meetings, and support for patients in befriending schemes with volunteers. All interventions will be provided to patients with SMI, delivered over a six-month period and evaluated with assessments at baseline and after six and 12 months. We will conduct nine trials including non-controlled trials, non-randomised controlled trials and randomised controlled trials (RCTs). Core outcome criteria will be used across all studies. However, details of study delivery and additional outcome criteria vary to accommodate local contexts, interests and priorities. The studies will be analysed separately, but with the option to compare and combine findings. DISCUSSION: The approach provides the opportunity to learn from commonalities and differences in the results and experiences across the three resource-oriented approaches and the three countries. If successfully implemented the studies can lead to more extensive research and are expected to inform health policies and clinical practice of community care for patients with SMI in the three participating countries and other LMICs. TRIAL REGISTRATION: All RCTs were registered prospectively and non-randomised trials retrospectively within the ISRCTN Registry. DIALOG+ in Uganda: ISRCTN25146122 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Colombia: ISRCTN83333181 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Bosnia-Herzegovina: ISRCTN13347129 (Date of Registration: 20/11/2018, prospective); Volunteer Support in Uganda: ISRCTN86689958 (Date of Registration: 04/03/2019, retrospective); Volunteer Support in Colombia: ISRCTN72241383 (Date of Registration: 04/03/2019, retrospective);Volunteer Support in Bosnia-Herzegovina: ISRCTN51290984 (Date of Registration: 20/11/2018, prospective); Family Involvement in Uganda: ISRCTN78948497 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Colombia: ISRCTN11440755 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Bosnia-Herzegovina: ISRCTN13347355 (Date of Registration: 20/11/2018, prospective).

Possibilities for the future of global mental health: a scenario planning approach.

BACKGROUND: Global mental health is a widely used term describing initiatives in policies, research and practice to improve the mental health of people worldwide. It has been gaining momentum over the last 10 years, reflected in increasing funding opportunities, training programmes, and publications. In light of the rising importance of global mental health and the various uncertainties about its future directions, this paper explores what the future may hold for global mental health in 30 years' time. METHOD: A scenario planning method was used, involving a workshop with experts from four continents and a range of backgrounds, including clinical and academic psychiatry, psychology, art and music therapy, service user advisory role, funder of global health research and post-graduate students. RESULTS: Six distinct scenarios that describe potential future situations were developed: universal standards for care; worldwide coordination of research; making use of diversity; focus on social factors; globalised care through technology; mental health as a currency in global politics. CONCLUSIONS: These scenarios consider different social, economic, scientific and technological drivers and focus on distinct aspects. Some reflect a global application of possible trends in mental health, whilst others apply general global developments to mental health care. They are not fixed forecasts, but instead may help to promote discussion and debate about further developments and decisions.

How to make carer involvement in mental health inpatient units happen: a focus group study with patients, carers and clinicians.

BACKGROUND: Carers are family members or friends who support people with a mental health problem without being paid. Carer involvement in mental health treatment has been consistently supported by research evidence and promoted by policies but its implementation rates are poor. Particularly when patients are treated in inpatient units, carers often report being left without information or being excluded from decisions about treatment. In this study we have explored, along with staff perspectives, views of patients and carers who had a recent experience of inpatient mental health care on how to improve the implementation of carer involvement in inpatient care. METHODS: Sixteen focus groups were held with carers, patients and clinicians in London, United Kingdom. We included staff working in inpatient units and patients and carers who had experience of inpatient care in the last five years. Data from focus groups were analysed using thematic analysis. RESULTS: Eighty six participants in total (31 service users, 22 carers and 33 clinicians) attended the focus groups. Participants identified that generally, carer involvement should happen as soon as possible after admission, although this may be challenging in some cases. Carer involvement should include receiving information, participating in decisions about care and discharge and receiving emotional support by staff. When carers are involved, their personal knowledge of the patient's condition should be utilised. Challenges to carer involvement may include problems with identifying carers during a mental health crisis, obtaining valid patient consent, sharing appropriate information, and contacting and engaging carers. Additionally, it was perceived that all the ward staff need to be actively engaged in order to make carer involvement happen and this cannot be left only to specifically trained clinicians. CONCLUSIONS: These findings identify basic components that all family interventions in inpatient units should have. Further studies are needed to explore how and if purposively designed clinical interventions can improve carer involvement in inpatient treatment and, consequently, patient outcomes.

Social isolation in mental health: a conceptual and methodological review.

PURPOSE: Social isolation and related concepts have been discussed increasingly in the field of mental health. Despite this, there is a lack of conceptual clarity and consistency in the definition and operationalisation of these terms. This review aimed to provide a clear framework for social isolation and related concepts, and to identify well-established measures in the field of mental health for each conceptual domain discussed. METHODS: We used an iterative strategy of expert consultation and literature searching. A multi-disciplinary group of senior academics was consulted both before and after the literature searching to identify relevant terms, conceptual papers, or recommended measures. Our conceptual framework was also validated through expert consultation. We searched the Web of Science database using terms suggested by experts and subsequently identified further relevant studies through review articles and by reading full texts and reference lists of included studies. A narrative synthesis was conducted. RESULTS: We developed a model with five domains incorporating all the concepts relevant to social isolation in regular use in the mental health research literature. These five domains are: social network-quantity; social network-structure; social network-quality; appraisal of relationships-emotional; and appraisal of relationships-resources. We also identified well-developed measures suitable for assessing each of the five conceptual domains or covering multi-domains. CONCLUSIONS: Our review proposes a conceptual model to encompass and differentiate all terms relating to social isolation. Potential uses are in allowing researchers and intervention developers to identify precisely the intended outcomes of interventions, and to choose the most appropriate measures to use in mental health settings.