Mexican Psychiatric Trainees' Attitudes Towards People with Mental Illness: A Qualitative Study.

Despite their training, psychiatrists have been found to have negative attitudes towards people with mental illness, including the patients they treat. Similarly, studies focused on service users have identified psychiatrists as a source of stigma. Even though negative attitudes in psychiatrists have been identified in different countries and settings, in Mexico the attitudes of these professionals have never been assessed. Because of this, we invited psychiatric trainees from a hospital in Mexico to participate in individual interviews to describe their opinions regarding mental health-related stigma, to evaluate their attitudes towards people with mental illness and to identify factors that could be influencing their attitudes. Interviews were audio recorded, transcribed and analysed using thematic analysis. A total of 29 trainees participated in the study. The results suggested that trainees recognised psychiatrists can have negative attitudes towards people with mental illness, such as poor empathy, judgement and labelling, and mainly towards patients considered difficult and with borderline personality disorder. Participants recognised these attitudes can influence their relationship with patients, and considered it is necessary to develop interventions to improve their own attitudes and reduce mental health stigma. From this study we concluded Mexican psychiatrists are not free from stigma towards people with mental illness. However, Mexican psychiatric trainees are interested in improving their attitudes and reactions towards their patients.

Mental Health Service Users' Perceptions of Stigma, From the General Population and From Mental Health Professionals in Mexico: A Qualitative Study.

Negative attitudes towards people with mental health disorders have been widely studied and identified in the general population, and even within health care professionals. Moreover, studies focused on service users have also identified mental health professionals, including psychiatrists, as a source of stigma. However, in Mexico and Latin America few studies have been conducted addressing this issue. To explore mental health service users' perceptions of stigma by members of the general population and by psychiatrists in Mexico, service users at a psychiatric hospital in Mexico were invited to participate in either focus groups or individual interviews, which were audio recorded, transcribed and analysed using thematic analysis. A total of 47 service users participated in this study. The results suggested that participants were not only aware of the possible consequences of mental health related stigma, but they have also experienced stigmatisation for having a mental illness. Participants also considered psychiatrists can hold negative attitudes towards people with mental illness, something that can represent a barrier for them to have optimal quality of care. Therefore, participants agreed that these attitudes should be addressed to improve the care they received from these professionals. This study suggests that, like members of the general population, psychiatrists are also considered as a source of stigma by people with mental illness in Mexico. These findings not only add to previous work conducted in Mexico and other countries, they also confirm the importance of addressing negative attitudes in this group of health professionals.

Family intervention in a prison environment: A systematic literature review.

BACKGROUND: The prison population in England and Wales is approximately 85,000, and elevated rates of mental health difficulties have been reported among the prisoners. Despite frequent recommendations for family interventions to optimise prisoner outcomes, the evidence for its use and impact in prison remain unclear. AIM: The aim of the study is to conduct a systematic review of published literature on family interventions in prisons. METHODS: Embase, PsychINFO and Medline were searched using terms for family interventions and for prisoners or young offenders. No limit was imposed on study design, but, for inclusion, we required that papers were written in English and published in peer-reviewed journals. RESULTS: Nine hundred eighty-three titles were retrieved. Twenty-two met criteria for inclusion. Three were case studies, 12 were descriptive, 6 were quasi-experimental and one was a randomised controlled trial. Interventions and study methods were too heterogeneous for meta-analysis. All studies gave positive conclusions about family interventions, but empirical data on effectiveness were slight. CONCLUSIONS: Consistency in findings across the wide-ranging studies suggested that family therapies may indeed be helpful for prisoners and their families, so further research is warranted. The fact that a randomised controlled trial proved feasible should encourage researchers to seek more robust data and to determine which form of intervention is effective and in which circumstances. It would also be useful to develop an improved understanding of mechanisms of change. Copyright © 2016 John Wiley & Sons, Ltd.

Treating Multiple Incident Post-Traumatic Stress Disorder (PTSD) in an Inner City London Prison: The Need for an Evidence Base.

BACKGROUND: Mental health problems have been found to be more prevalent in prison populations, and higher rates of post-traumatic stress disorder (PTSD) have been found in sentenced populations compared to the general population. Evidence-based treatment in the general population however has not been transferred and empirically supported into the prison system. AIMS: The aim of this manuscript is to illustrate how trauma focused work can be applied in a prison setting. METHOD: This report describes a two-phased approach to treating PTSD, starting with stabilization, followed by an integration of culturally appropriate ideas from narrative exposure therapy (NET), given that the traumas were during war and conflict, and trauma-focused cognitive behavioural therapy (TF-CBT). RESULTS: PTSD and scores on paranoia scales improved between start and end of treatment; these improvements were maintained at a 6-month follow-up. CONCLUSION: This case report 1 illustrates successful treatment of multiple incident PTSD in a prison setting using adaptations to TF-CBT during a window of opportunity when individuals are more likely to be free from substances and live in relative stability. Current service provision and evidence-based practice for PTSD is urgently required in UK prisons to allow individuals to engage in opportunities to reduce re-offending, free from mental health symptoms.

Evaluation of an anti-stigma intervention for Mexican psychiatric trainees.

BACKGROUND: There is research evidence regarding the presence of stigmatising attitudes in psychiatrists towards people with mental illness, but a lack of studies and interventions focused on this issue in low and middle-income countries. AIMS: To assess the feasibility of implementing an anti-stigma intervention for Mexican psychiatric trainees, and its potential effects. METHODS: This study comprised a pre-post design with outcome measures compared between baseline and 3-month follow-up. Quantitative outcome measures were used to evaluate the potential effects of the intervention, whilst the process evaluation required the collection and analysis of both quantitative and qualitative data. RESULTS: Twenty-nine trainees (25% of those invited) participated in the intervention, of whom 18 also participated in the follow-up assessment. Outcome measures showed the intervention had moderately large effects on reducing stereotypes and the influence of other co-workers on trainees' own attitudes. The main mechanisms of impact identified were recognition of negative attitudes in oneself and colleagues, self-reflection about the impact of stigma, one's own negative attitudes and recognition of one's ability to make change. Participants accepted and were satisfied with the intervention, which many considered should be part of their routine training. However, trainees' work overload and lack of support from the host organisation were identified as barriers to implement the intervention. CONCLUSIONS: A brief anti-stigma intervention for Mexican psychiatric trainees is feasible, potentially effective, well accepted and was considered necessary by participants. This study also suggests mechanisms of impact and mediators should be considered for developing further interventions, contributing to reducing the damaging effects that mental health-related stigma has on people's lives.

Prospective cohort study of mental health during imprisonment.

BACKGROUND: Mental illness is common among prisoners, but little evidence exists regarding changes in symptoms in custody over time. AIMS: To investigate the prevalence and predictors of psychiatric symptoms among prisoners during early custody. METHOD: In a prospective cohort study, 3079 prisoners were screened for mental illness within 3 days of reception. To establish baseline diagnoses and symptoms, 980 prisoners were interviewed; all remaining in custody were followed up 1 month and 2 months later. RESULTS: Symptom prevalence was highest during the first week of custody. Prevalence showed a linear decline among men and convicted prisoners, but not women or remand prisoners. It decreased among prisoners with depression, but not among prisoners with other mental illnesses. CONCLUSIONS: Overall, imprisonment did not exacerbate psychiatric symptoms, although differences in group responses were observed. Continued discussion regarding non-custodial alternatives for vulnerable groups and increased support for all during early custody are recommended.

Supported employment: randomised controlled trial.

BACKGROUND: There is evidence from North American trials that supported employment using the individual placement and support (IPS) model is effective in helping individuals with severe mental illness gain competitive employment. There have been few trials in other parts of the world. AIMS: To investigate the effectiveness and cost-effectiveness of IPS in the UK. METHOD: Individuals with severe mental illness in South London were randomised to IPS or local traditional vocational services (treatment as usual) (ISRCTN96677673). RESULTS: Two hundred and nineteen participants were randomised, and 90% assessed 1 year later. There were no significant differences between the treatment as usual and intervention groups in obtaining competitive employment (13% in the intervention group and 7% in controls; risk ratio 1.35, 95% CI 0.95-1.93, P = 0.15), nor in secondary outcomes. CONCLUSIONS: There was no evidence that IPS was of significant benefit in achieving competitive employment for individuals in South London at 1-year follow-up, which may reflect suboptimal implementation. Implementation of IPS can be challenging in the UK context where IPS is not structurally integrated with mental health services, and economic disincentives may lead to lower levels of motivation in individuals with severe mental illness and psychiatric professionals.

Facilitators and barriers to implementing clinical care pathways.

BACKGROUND: The promotion of care pathways in the recent Governmental health policy reports of Lord Darzi is likely to increase efforts to promote the use of care pathways in the NHS. Evidence on the process of pathway implementation, however, is sparse and variations in how organisations go about the implementation process are likely to be large. This paper summarises what is known about factors which help or hinder clinicians in adopting and putting care pathways into practice, and which consequently promote or hinder the implementation of scientific evidence in clinical practice. DISCUSSION: Care pathways can provide patients with clear expectations of their care, provide a means of measuring patient's progress, promote teamwork on a multi-disciplinary team, facilitate the use of guidelines, and may act as a basis for a payment system. In order to achieve adequate implementation, however, facilitators and barriers must be considered, planned for, and incorporated directly into the pathway with full engagement among clinical and management staff. Barriers and/or facilitators may be present at each stage of development, implementation and evaluation; and, barriers at any stage can impede successful implementation. Important considerations to be made are ensuring the inclusion of all types of staff, plans for evaluating and incorporating continuous improvements, allowing for organisational adaptations and promoting the use of multifaceted interventions. SUMMARY: Although there is a dearth of information regarding the successful implementation of care pathways, evidence is available which may be applied when implementing a care pathway. Multifaceted interventions which incorporate all staff and facilitate organisational adaptations must be seriously considered and incorporated alongside care pathways in a continuous manner. In order to better understand the mechanism upon which care pathways are effective, however, more research specifically addressing conditions under which providers become engaged in using care pathways is needed.

Coerced medication in psychiatric inpatient care: literature review.

AIM: This paper is a report of a narrative review of the coercive use of medication in inpatient psychiatric care to identify a demographic and clinical profile of patients who are forcibly medicated, and to examine patient and staff views of this practice. BACKGROUND: Lack of compliance with medication is associated with quicker relapse and increased risk to self and others in mental disorder. It is this increased risk which provides the ethical and legal grounds for detaining and treating psychiatric patients without their consent. Legislation for involuntary psychiatric treatment exists in all European Union member states and in other western countries. DATA SOURCES: Online bibliographic databases from 1980 to 2008 were searched, including British Nursing Index, CINAHL, PsycINFO, EMBASE and MEDLINE. Search terms relating to coercion, force, chemical restraint, rapid tranquilization, inpatients and psychiatry were used. REVIEW METHODS: Titles and abstracts were reviewed. All peer reviewed papers concerning coercion in the administration of medication in inpatient psychiatric care were included and a narrative review was conducted. RESULTS: Fourteen papers from seven countries were included. Patients who have experience coerced medication tend to be aged in their 30s, with a diagnosis of schizophrenia, bipolar or other psychotic disorders, and are often involuntarily admitted. Assault or threat of assault is the main reason for giving forced medication. CONCLUSION: There is a dearth of literature in the area of coercion in administration of medication and much more research is needed examining all aspects of this contentious practice.

Psychiatric intensive care units: a literature review.

BACKGROUND: Psychiatric Intensive Care Units (PICU) have been part of most inpatient psychiatric services for some time, although information about their functioning and outcome has not previously been collated. AIM: To conduct a systematic literature review to assess the current state of knowledge about such services. METHOD: A search of electronic databases was undertaken, followed by obtaining additional references from items obtained. RESULTS: Over 50 papers in English containing some empirical data were identified. Most studies were retrospective. Typical PICU patients are male, younger, single, unemployed, suffering from schizophrenia or mania, from a Black Caribbean or African background, legally detained, with a forensic history. The most common reason for admission is for aggression management, and most patients stay a week or less. Evidence of the efficacy of PICU care is very poor. CONCLUSIONS: Most research so far has been small scale, and more substantial work using better methodologies is clearly required.

Substance use and at-risk mental state for psychosis in 2102 prisoners: the case for early detection and early intervention in prison.

AIM: Prisoners exhibit high rates of substance use and mental health problems. In the present study, we sought to gain a detailed understanding of substance use amongst young prisoners to inform early detection and early intervention strategies in a prison setting. METHODS: This is a cross-sectional study of 2102 prisoners who were screened by the London Early Detection and Prevention in Prison Team (LEAP). Data on the use of substances were collected including age of first use, recent use, duration of use and poly-drug use. The Prodromal Questionnaire - Brief Version was used to screen for the at-risk mental state. RESULTS: We found high rates of lifetime and recent use and low age of first use of a number of substances. We also found strong associations between substance use and screening positive for an at-risk mental state. Logistic regression analysis confirmed that use of any drug in the last year, poly-drug and early use, as well as heavy alcohol use, were related to an increased risk of screening positive. CONCLUSIONS: Substance use in the prison population is not only widespread and heavy but is also strongly linked with a higher risk of developing mental health problems. The need for early detection and early intervention in prison is discussed.

Prison and Community Populations at Ultra-High Risk of Psychosis: Differences and Challenges for Service Provision.

OBJECTIVE: The aim of the study was to explore the feasibility of expanding a community service for early detection of psychosis into a local London prison for men in the United Kingdom. METHODS: All new receptions to a local prison for men in South London were approached for routine screening. Those who met criteria for being at ultra-high-risk of psychosis were compared with a help-seeking sample from the community who met the same criteria. Clinical and sociodemographic characteristics were compared to determine whether the prison and community populations had similar profiles and mental health needs. RESULTS: Of 891 prisoners screened, 44 (5%) met criteria for being at ultra-high risk of psychosis. The community sample consisted of 42 participants. Compared with the community group, prison participants had lower scores on almost all symptom measures, were less likely to have remained in school and completed exams, and were more likely to be in short-term accommodations and to be of black race-ethnicity. Lifetime use of illicit drugs was similar between the groups, but recent use was much higher in the prison group. CONCLUSIONS: Expanding community services into custodial settings should take into account the different environment and needs of the prisoner population. Specifically, early detection and intervention services should target a broad range of mental health problems rather than psychosis alone.

Identifying men at ultra high risk of psychosis in a prison population.

BACKGROUND: The prevalence of psychotic disorders among prisoners is relatively high. We sought to investigate the prevalence of men who have a very high risk of developing psychosis in a prison population. METHODS: The Prodromal Questionnaire - Brief Version (Loewy, Pearson, Vinogradov, Bearden and Cannon, 2011), was used to screen newly-arrived prisoners in a London prison for features associated with an increased risk of psychosis. Concurrent validity was evaluated using the Comprehensive Assessment for At Risk Mental State (Yung et al., 2005). RESULTS: 750 prisoners were screened and 301 were underwent further clinical assessment. 5% the total number of those screened met diagnostic criteria for the ARMS and 3% had recently developed a first episode of psychosis. Using endorsement of items that also caused distress, the PQ-B predicted an ARMS or a psychotic disorder with 90% sensitivity and 44% specificity. CONCLUSIONS: The PQ-B is effective in identifying people who are vulnerable to developing psychosis in a prison population.

Randomized controlled trial of supported employment in England: 2 year follow-up of the Supported Work and Needs (SWAN) study.

Studies from North America have concluded that supported employment using the Individual Placement and Support (IPS) model is effective in helping individuals with severe and persistent mental illness gain competitive employment. The aim of this study was to investigate the effectiveness and cost-effectiveness of IPS in England in patients followed up for 2 years. Patients with severe mental illness were randomised to IPS or local vocational services (treatment as usual). Service use and costs were measured. Two hundred-nineteen participants were randomised, and 86% re-assessed 2 years later. In the multivariate analysis, relatively low rates of competitive employment were found in both the intervention group and the treatment as usual group, although significantly more patients obtained competitive employment in the treatment arm (22% vs. 11%, p=0.041). There were no significant differences in costs. The employment rate among participants receiving IPS was lower than in previously published reports, and the number needed to treat to obtain the benefit of IPS was relatively high. This may reflect difficulties in the implementation of IPS where it is not structurally integrated within mental health teams, as well as economic disincentives which lead to lower levels of motivation for patients and mental health professionals.

Messages to use in population-level campaigns to reduce mental health-related stigma: consensus development study.

AIM: To develop and measure consensus about which type of message should be included in population-level campaigns to reduce mental health-related stigma. METHODS: A panel of 32 experts attending an international conference on mental health stigma participated in a consensus development exercise. A modified nominal group technique was used incorporating two voting rounds, an overview of research evidence and group discussion. RESULTS: There was high consensus (> or = 80%) regarding the inclusion of two of the message types presented--(i) recovery-oriented and (ii) see the person messages, and reasonable consensus (> or = 70%) regarding (iii) social inclusion/human rights and (iv) high prevalence of mental disorders messages. Ratings differed according to whether the participant was a psychiatrist or had personal experience of mental ill health. Analysis of the qualitative data revealed four themes: (i) benefits of messages countering the 'otherness' of people with mental ill health; (ii) problematic nature of messages referring to aetiology; (iii) message impact being dependent on the particular audience; (iv) need for specific packages of messages. CONCLUSIONS: This study supports the use of recovery-oriented messages and see the person messages. Social inclusion/human rights messages and high prevalence of mental disorders messages also merit consideration.

Clinical pathways in psychiatry.

This editorial summarises the literature on the use of care pathways in psychiatry. Further, it considers the case-mix clusters used in care pathways in relation to health service financial tariff and currency systems, and also reviews the evidence for the effectiveness of clinical pathways.