Measuring dissociation across adolescence and adulthood: developing the short-form Cernis Felt Sense of Anomaly scale (CEFSA-14).

BACKGROUND: Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, 'felt sense of anomaly' (FSA), and developed a corresponding measure, the Cernis Felt Sense of Anomaly (CEFSA) scale. AIMS: We aimed to develop a short-form version of the CEFSA that is valid for adolescent and adult respondents. METHOD: Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges. RESULTS: LSEM indicated 25 items of the original 35-item CEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (CEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach's alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation. CONCLUSIONS: The CEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.

Criminal sanctions for suicidality in the 21st Century UK.

Criminal sanctions including court orders, prosecution and imprisonment persist as responses to suicidality in the UK even where there is no public danger. Their prevalence, the level of clinical involvement and outcomes are unclear. There is an urgent need to examine the national picture of harms, benefits and the responsibilities of mental health professionals.

The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs.

BACKGROUND: The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation. METHODS: In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted. RESULTS: The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion. CONCLUSIONS: The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

Cultural variations in wellbeing, burnout and substance use amongst medical students in twelve countries.

High levels of stress, burnout, and symptoms of poor mental health have been well known among practicing doctors for a number of years. Indeed, many health systems have formal and informal mechanisms to offer support and treatment where needed, though this varies tremendously across cultures. There is increasing evidence that current medical students, our doctors of the future, also report very high levels of distress, burnout, and substance misuse. We sampled large groups of medical students in 12 countries at the same time and with exactly the same method in order to aid direct comparison. 3766 students responded to our survey across five continents in what we believe is a global first. Our results show that students in all 12 countries report very high levels of 'caseness' on validated measures of psychiatric symptoms and burnout. Rates of substance misuse, often a cause of or coping mechanism for this distress, and identified sources of stress also varied across cultures. Variations are strongly influenced by cultural factors. Further quantitative and qualitative research is required to confirm our results and further delineate the causes for high rates of psychiatric symptoms and burnout. Studies should also focus on the implementation of strategies to safeguard and identify those most at risk.

Applying the triple bottom line of sustainability to healthcare research-a feasibility study.

OBJECTIVE: The triple bottom line (TBL) of sustainability is an important emerging conceptual framework which considers the combined economic, environmental and social impacts of an activity. Despite its clear relevance to the healthcare context, it has not yet been applied to the evaluation of a healthcare intervention. The aim of this study was to demonstrate whether doing so is feasible and useful. DESIGN: Secondary data analysis of a 12-month randomized controlled trial. SETTING: Community based mental health care. PARTICIPANTS: Patients with chronic psychotic illnesses (n = 333). INTERVENTION(S): Community treatment orders. MAIN OUTCOME MEASURE(S): Financial and environmental (CO2 equivalent) costs of care, obtained from healthcare service use data, were calculated using publicly available standard costs; social sustainability was assessed using standardized social outcome measures included in the trial data. RESULTS: Standardized costing and CO2e emissions figures were successfully obtained from publicly available data, and social outcomes were available directly from the trial data. CONCLUSIONS: This study demonstrates that TBL assessment can be retrospectively calculated for a healthcare intervention to provide a more complete assessment of the true costs of an intervention. A basic methodology was advanced to demonstrate the feasibility of the approach, although considerable further conceptual and methodological work is needed to develop a generalizable methodology that enables prospective inclusion of a TBL assessment in healthcare evaluations. If achieved, this would represent a significant milestone in the development of more sustainable healthcare services. If increasing the sustainability of healthcare is a priority, then the TBL approach may be a promising way forward.

Cognitive appraisals of dissociation in psychosis: a new brief measure.

BACKGROUND: Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable. AIMS: The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms. METHOD: Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test-re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms. RESULTS: A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test-re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%). CONCLUSIONS: The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.

Supported decision making for people with mental health disorders in clinical practice: a systematic review.

Objectives: The Convention on the Rights of Persons with Disabilities (CRPD) was adopted at the United Nations Assembly in 2006. The main aim of the convention is to ensure equal rights for people with disabilities including the expression of people's own "will and preferences" concerning health treatment. Article 12 demands the respect of a person's "rights, will and preferences" (CRPD) and suggests supported decision making (SDM) when possible. The aim of this review was to gather information regarding the SDM implementation from a clinical perspective for people with mental health disorders.Methods: A systematic literature search was performed on electronic databases MEDLINE, PsycARTICLES, and PsycINFO using the keywords "supported decision making" and "UN convention on the rights of persons with disabilities" in March 2018.Results: Eleven articles were included in the final review, which focussed on three themes: (1) different models of SDM, (2) stakeholder views, and (3) challenges for implementation. A limited number of papers described clinical models that had good theoretical consistency with SDM. The main challenges of implementation related to critical situations when "will and preferences" are poorly understood or appear contradictory. Future studies should assess specific models of SDM implementation, including related outcomes and process measures.

Psychological wellbeing, burnout and substance use amongst medical students in New Zealand.

Medical students are thought to have increased pressures in study life beyond that of their peers. This could impact their psychological wellbeing, burnout and substance use, impeding a smooth transition into the health workforce. A cross-sectional electronic survey of one of New Zealand's two medical schools was undertaken, and students in all years were invited to participate through email. Two hundred and twenty students completed the survey. Forty-six students (21%) reported that they were currently seeing a GP or Allied Healthcare Professional (AHP) for their mental ill-health. Seventy-seven students (35%) reported having taken cannabis during medical school. The number of respondents reaching the threshold for CAGE, and thus demonstrating problem drinking, was 40 (18%). Additionally, burnout levels were scored, with 150 students (68%) classifying as disengaged and 169 (77%) as suffering from exhaustion on the Oldenburg burnout measure. Going forwards, organizational bodies including governments and medical schools should place emphasis on the importance of optimizing medical student wellbeing, including resilience training and improved workforce wellbeing planning, to positively impact not just medical students as they progress to doctors, but for patients, and the healthcare system as a whole.

A descriptive study of mental health and wellbeing among medical students in Portugal.

In studies around the world, medical students have been identified as being at high risk for poor mental wellbeing, burnout and mental ill health. This can lead on to poorer physical health, substance misuse and reduced academic performance. We surveyed Portuguese medical students to assess burnout (using the Oldenburg Burnout Inventory, OLBI), minor psychiatric illness (General Health Questionnaire 12, GHQ12) and alcohol misuse (CAGE questionnaire). A total of 622 medical students participated in the study. We found high levels of exhaustion (89%), disengagement (81%) and minor psychiatric illness (91%). The CAGE questionnaire was positive in 10% of students. Future research is required to confirm these results, assess and monitor local and global trends and investigate interventions at both local and national level to improve the mental wellbeing of medical students.

Effect of Assertive Community Treatment for Patients with Substance Use Disorder: A Systematic Review.

PURPOSE: Substance use disorders (SUD) are an important health issue internationally. Traditional outpatient programmes often do not adequately address the substantial medical and social needs and in addition many patients have difficulties accessing the care needed. The assertive community treatment (ACT) model was originally developed for patients with a severe mental illness but has been adapted for patients with SUD by integrating specific SUD treatments into the traditional ACT model. This paper aims to assess the effectiveness of ACT for patients with SUD on a number of measures. METHODS: We performed a systematic review of ACT interventions for patients with SUD by analyzing randomized controlled studies published before June 2017 found on the electronic databases PsychINFO, MEDLINE, PsychARTICLES. Eleven publications using 5 datasets were included in the analysis. Quality of studies was analyzed using the JADAD scale or Oxford quality scoring system. Outcome measures used were substance use, treatment engagement, hospitalization rates, quality of life, housing status, medication compliance and legal problems. Patients included in the studies had a diagnosis of SUD. Two datasets included homeless patients and 2 datasets included patients with high service use. RESULTS AND CONCLUSIONS: The results of the very few existing randomized control studies are mixed. Treatment engagement was higher for ACT in 4 datasets. One dataset reported higher service contact rates for the ACT group than for controls. In 2 datasets a positive effect on hospitalization rates was found. Higher fidelity to the ACT model appears to improve outcomes. Substance use reduced only in half of the datasets, of which only one showed a significant reduction in the ACT group. Overall, ACT is a promising approach that may be useful for promoting treatment engagement for patients with SUD. According to earlier studies on patients with severe mental illness, patients with high inpatient service use benefit most from this assertive approach. We hypothesize that a similar high need user group among patients with SUD might benefit most from ACT. Further research is needed to examine which types of clinical interventions might help difficult-to-engage patients with addictions.

Wellbeing and burnout amongst medical students in England.

The wellbeing of doctors in training is currently under the spotlight. The British Medical Association (BMA) has committed to understanding issues of wellbeing amongst medical students. Medical students from England were asked to complete an online survey pertaining to wellbeing. 84 students responded. Results show 29% of respondents were given a mental health diagnosis whilst at medical school, and 82% could be classified as 'disengaged' and 85% 'exhausted' using the Oldenburg Burnout Scale. This demonstrates the need for further surveys with an increased number of respondents in order to gather more evidence surrounding these high rates of mental health issues. Support and preventative measures for medical students are required.

Mental health and wellbeing among Moroccan medical students: a descriptive study.

Medical students are tomorrow's healthcare professionals (HCPs), and their role in the design and delivery of healthcare in the future is crucial. Following an invitation to participate in a global call on mental health and wellbeing among medical students, it was decided to include Moroccan medical students based in the Faculty of Medicine and Pharmacy of Rabat between March 2019 and May 2019. Six hundred and thirty-seven medical students from the Faculty of Medicine and Pharmacy of Rabat responded to the BMA (British Medical Association) online survey, with females representing 66% of students. Medical studies were considered the main source of stress by 90% of respondents. The CAGE test screened 5% of students to be at risk of alcohol related health problems. Thirteen per cent of respondents reported substance misuse, 20% consumed alcohol, and 13% reported Illicit drug use. Almost half of Moroccan medical students had minor psychiatric disorder according to GHQ-12. Very high rates of burnout were found among undergraduate medical students, at 93%, and 68% reported, respectively, exhaustion and disengagement. This study showed very high levels of burnout among Moroccan undergraduate medical students. These results draw attention to the poor mental wellbeing of medical students. It is important that careful steps are put in place to support medical students who need this help.

Wellbeing and mental health amongst medical students in Jordan: a descriptive study.

Across the globe medical students are experiencing high levels of depression, anxiety, and psychological distress. This can ultimately lead to poor academic performance, substance misuse and/or concerns over clinical practice and fitness to practice. We surveyed Jordanian medical students to assess burnout (using the Oldenburg Burnout Inventory, OLBI), minor psychiatric illness (General Health Questionnaire 12, GHQ12) and alcohol/substance abuse (CAGE questionnaire). Results indicate a high level of exhaustion (91%), disengagement (87%) and 'minor' psychiatric illness (92%). OLBI and GHQ12 scores were found to correlate positively (p < 0.001). The CAGE questionnaire was positive in 8% of students. Further research is required to confirm these results and compare them to the global burden of mental illness in medical students. Medical students in Jordan should be considered a high-risk group for burnout and mental health problems and strategies should be employed to recognise and appropriately manage those most at risk.

Wellbeing and burnout in medical students in India; a large scale survey.

Medical students in India completed an anonymous online questionnaire regarding mental health and wellbeing, including Oldenburg burnout ratings, CAGE questionnaires, and general health questionnaire (GHQ12). Out of 597 student responses, over 80% were characterised as experiencing burnout. This study highlights the need to further examine this issue, including possible causes and solutions.

Wellbeing and mental health amongst medical students from Hong Kong.

Medical students are a known high-risk group for mental health issues. This study aimed to survey the psychological well-being of medical students from Hong Kong, a known stressful city. This study is part of a wider effort to compare the psychological well-being of medical students world-wide. We invited medical students from Hong Kong to complete a self-report questionnaire online. The questionnaire included questions on demographics, known mental health issues, sources of psychological stress, and substance use. It also included the cut-annoyed-guilty-eye (CAGE) questionnaire, Short-Form General Health Questionnaire (GHQ-12), and the Oldenburg Burnout Inventory (OLBI). There were 123 responses. Our results suggest high levels of psychological morbidity and distress among medical students in Hong Kong. 87% screened positive for minor psychiatric disorders on the GHQ-12 and 95% met OLBI thresholds for burnout. Female respondents demonstrated significantly higher mean GHQ-12 scores than male. Despite the apparent high prevalence of mental ill-health in this population, only 15% of respondents reported receiving professional help.

Wellbeing and burnout among medical students in Wales.

Medical students' wellbeing and mental health requires nurturing in order for them to build success in their careers, help people while doing so, and to be happy. To better characterise the current state of wellbeing in medical schools in Wales, medical students from Cardiff and Swansea Universities were asked to complete an online survey as part of a larger international survey regarding their mental health and wellbeing. 266 students responded out of approximately 2150, a rate of 12%. 44 students received a mental health diagnosis whilst at medical school (predominantly depression or anxiety), 65 scored threshold for concerning alcohol consumption using the CAGE questionnaire, and 224 and 230 students reached threshold for the disengagement and exhaustion components of the Oldenburg Burnout Scale, respectively.

Stressors, psychological distress, and mental health problems amongst Brazilian medical students.

In line with studies from around the world, several studies have shown equal or higher rates of anxiety, depression, alcohol and other drug use, and burnout in medical students in Brazil. The aim of the present study was to identify difficulties Brazilian medical students face regarding stressors, psychological distress, and psychiatric morbidity using standardized reliable and valid instruments. In addition, this study also investigated differences associated with sex. Students (n = 129) were asked to complete a one-off survey from January to June 2019, including demographics, previous mental health issues, CAGE, GHQ-12, and OLBI. A higher prevalence of previous mental disorders was found in comparison to during the medical course. This may suggest that perhaps students are under more stress or that they form a more vulnerable sub-population in medical school in comparison with the general population. However, the types of mental disorders before and during the undergraduate course appear to vary. During the course, they show higher levels of anxiety rather than that of depression. Before commencing the course, they showed higher levels of depression rather than anxiety. Cannabis and ecstasy experimentation levels were higher than those of students from other courses in previous studies. The opposite was true for stimulants. Just over a quarter reported alcohol abuse above the CAGE cut-off point. The levels of psychological distress and burnout were extremely high, and women had even higher levels. Male respondents were more likely to have a history of mental ill-health, but female subjects scored higher on burnout. Overall over 80% students reported burnout. These findings are discussed in the context of Brazilian culture.

Mental health and wellbeing among Italian medical students: a descriptive study.

Medical students (MSs) are an important part of the workforce for delivery of tomorrow's healthcare. Their ever changing knowledge base and long periods of training may significantly affect their mental health and wellbeing over the years. Following a global call for participation, it was decided to include Italian medical schools based in the Universities of Ancona and Foggia between January and April 2019. Students were invited to participate in an online survey. A total of 360 completed responses were received and analysed. Of these, 8.6% of samples reported mental health issues whilst at medical school, ranking as follows: Anxiety Disorders > Major Depression > Eating Disorders > ADHD > Burnout Syndrome; 7.2% of them had been treated with psychotropic medications whereas 7.8% were self-medicating; 8.9% reported problems related to alcohol-drinking, and 22.8% admitted using illicit drugs (mostly cannabis and cocaine). The levels of burnout syndrome were quite low. It is important to ensure that the future workforce are looked after and, as the students are in the vulnerable age group, they should have access to early and prompt help-seeking and early interventions if needed.

A descriptive study of mental health and wellbeing of doctors and medical students in the UK.

Doctors and medical students are working in a system which is affecting their mental wellbeing and their ability to provide the best possible care for patients. The British Medical Association conducted an online survey of doctors and medical students in October 2018. In total, 4347 responses were received and analysed. Doctors working the longest hours appear to be most vulnerable to psychological and emotional disturbance. Older and more senior doctors are most likely to report that their working environment has impacted on their condition. Medical students and junior doctors report the highest rate of having a formally diagnosed mental health condition in the last 12 months. This may be because they are in the vulnerable age group when psychiatric disorders start. Junior doctors were least likely to be aware of how to access help or support. Older doctors, those working as SAS (Staff, Associate Specialists and Specialty) doctors and overseas qualified doctors are most likely to say they have asked for support in managing a problem from their employer but that no support was provided. It is important to recognize that doctors, in spite of stress and poor wellbeing, continue to work hard, which has both advantages and disadvantages. These findings highlight that the environment in which doctors work, train, and study affects their mental health, and for this reason careful consideration needs to be given to the type and level of support provision available to them, as well as the ease of access and awareness of such support.

A systematic review of co-responder models of police mental health 'street' triage.

BACKGROUND: Police mental health street triage is an increasingly common intervention when dealing with police incidents in which there is a suspected mental health component. We conducted a systematic review of street triage interventions with three aims. First, to identify papers reporting on models of co-response police mental health street triage. Second, to identify the characteristics of service users who come in to contact with these triage services. Third, to evaluate the effectiveness of co-response triage services. METHODS: We conducted a systematic review. We searched the following databases: Ovid MEDLINE, Embase, PsycINFO, EBSCO CINAHL, Scopus, Thompson Reuters Web of Science Core Collection, The Cochrane Library, ProQuest National Criminal Justice Reference Service Abstracts, ProQuest Dissertations & Theses, EThoS, and OpenGrey. We searched reference and citation lists. We also searched for other grey literature through Google, screening the first 100 PDFs of each of our search terms. We performed a narrative synthesis of our results. RESULTS: Our search identified 11,553 studies. After screening, 26 were eligible. Over two-thirds (69%) had been published within the last 3 years. We did not identify any randomised control trials. Results indicated that street triage might reduce the number of people taken to a place of safety under S136 of the Mental Health Act where that power exists, or reduce the use of police custody in other jurisdictions. CONCLUSIONS: There remains a lack of evidence to evaluate the effectiveness of street triage and the characteristics, experience, and outcomes of service users. There is also wide variation in the implementation of the co-response model, with differences in hours of operation, staffing, and incident response.