Recovery beyond clinical improvement - Recovery outcomes measured for people with bipolar disorder between 1980 and 2020.

BACKGROUND: Outcome measurement in bipolar disorder (BD) traditionally focused on clinical improvement without considering other domains. Improvement trajectories in clinical and social-functional domains are different and can simultaneously appear in one while not in other domains. Measuring personal recovery (PR) has become a priority internationally. This review explored the shift in research investigating operational recovery definitions and underpinning factors of recovery in BD over the past four decades. METHODS: Studies defining recovery domains (other than clinical recovery) in BD were systematically reviewed; operational recovery definitions and factors assessed in association with recovery were thematically categorised and integrated in a narrative synthesis. RESULTS: Thirty-three studies, comprising 3638 participants from 19 countries were included. Identified operational recovery definition themes included i) PR ii) social-functional (SFR), and iii) occupational-residential (ORR) recovery. Examined factors were grouped as demographic, clinical and psychosocial factors. Predominantly demographic factors were linked to ORR and clinical factors to SFR. Depressive symptomatology was the only clinical factor associated with PR. Research investigating psychosocial factors in PR is emerging and has showed that resilience and appraisals of mood seem to be associated with PR. LIMITATIONS: Studies not available in English or examining functioning without defining recovery were excluded. CONCLUSIONS: Earlier operational recovery definitions of ORR and SFR were often arbitrary and inconsistent, and predominantly focused on clinical and demographic underpinning factors. While research attempts to follow the significant policy shifts towards personalised care by measuring what matters to individuals and exploring broader underpinning psychosocial factors, it is still lagging behind.

Psychological factors in personal and clinical recovery in bipolar disorder.

BACKGROUND: Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy. METHODS: This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months. RESULTS: 107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes. LIMITATIONS: Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample. CONCLUSIONS: Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'.

BACKGROUND: Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour. AIMS: To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services. METHOD: Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis. RESULTS: Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities. CONCLUSIONS: The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area. DECLARATION OF INTEREST: D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

An analysis of whether a working-age ward-based liaison psychiatry service requires the input of a liaison psychiatrist.

Aims and method This article presents a 12-month case series to determine the fraction of ward referrals of adults of working age who needed a liaison psychiatrist in a busy tertiary referral teaching hospital. Results The service received 344 referrals resulting in 1259 face-to-face contacts. Depression accounted for the most face-to-face contacts. We deemed the involvement of a liaison psychiatrist necessary in 241 (70.1%) referrals, with medication management as the most common reason. Clinical implications A substantial amount of liaison ward work involves the treatment and management of severe and complex mental health problems. Our analysis suggests that in the majority of cases the input of a liaison psychiatrist is required.

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study.

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Opening the 'black box': liaison psychiatry services and what they actually do.

Aims and method To develop a simple, pragmatic typology to characterise the nature of liaison interventions delivered by a liaison service in a National Health Service setting. We carried out a retrospective electronic case-note review of referrals to a ward-based liaison psychiatry service. Results Three hundred and forty-four patients were referred to the service over a 12-month period. Ten different types of liaison interventions were identified, with the most common interventions being diagnosis (112 patients, 32.6%), medication management (57 patients, 16.6%), risk assessment and treatment (56 patients, 16.3% each). Mental Health Act work accounted for the greatest number of contacts per patient (median 7). Clinical implications There are inherent limitations in any single-site observational study, as site-specific results cannot be generalised to other liaison services. The intervention categories we developed, however, are easy to use and will provide a way of comparing and benchmarking the range of interventions delivered by different liaison psychiatry services.

Is Performance-Based Progress Testing in Psychiatry Feasible?

OBJECTIVE: The aim of this study was to explore if competency-based progress tests for postgraduate psychiatry are reliable, if they are able to discriminate trainees at different levels of training, and if they are able to demonstrate improvement of trainees' skills from 3 years of data. METHODS: Psychiatry trainees in the North Western Deanery, UK, were invited to participate in the annual progress test. The progress test simulated the Clinical Assessment of Skills and Competencies (CASC) exam, the final postgraduate examination for psychiatry trainees. The sum of global scores from all stations for each candidate was used for statistical analysis. Cronbach's alpha was used to calculate the interstation reliability. Analysis of variance (ANOVA) was used to explore if the progress test could discriminate between the three levels of trainees each year. Student's t test was used to explore if there was improvement and development of skills as a cohort progressed; ANOVA was used for the cohort with 3 years of data. RESULTS: The progress test is more likely to be reliable (alpha ≥ 0.8) when 12 stations are used. ANOVA revealed significantly improved scores with increasing level of seniority in 2012, with a mean total score increasing from 23.1 to 31.3 (p = 0.008) and 36.9 to 46.6 in 2013 (p = 0.004). In 2014, this effect was not observed, with a mean decreasing from 42.4 to 41.3. Over time, two cohorts demonstrated improving mean scores with Student's t tests from 26.4 to 32.4 (p = 0.01) and 26.9 to 42.6 (p = 0.01). The third cohort did not demonstrate a difference over time, with mean scores 23.1, 27.6, and 25.9 over 3 years. CONCLUSIONS: It is not conclusive if the progress test can accurately distinguish between trainee seniority or assess progress over time; possible explanations for non-significant results and further avenues of enquiry are discussed.

Messages from Manchester: pilot randomised controlled trial following self-harm.

Studies of therapeutic contact following self-harm have had mixed results. We carried out a pilot randomised controlled trial comparing an intervention (information leaflet listing sources of help, two telephone calls soon after presentation and a series of letters over 12 months) to usual treatment alone in 66 adults presenting with self-harm to two hospitals. We found that our methodology was feasible, recruitment was challenging and repeat self-harm was more common in those who received the intervention (12-month repetition rate 34.4% v. 12.5%).

Workplace-based assessments in psychiatry: evaluation of a whole assessment system.

OBJECTIVE: Work Place-Based Assessments (WPBAs) were introduced into psychiatry along with the new curriculum in 2005. The Royal College of Psychiatrists decided to pilot several WPBAs to ascertain their suitability. METHOD: Eight types of assessments (Case-Based Discussion, Assessment of Clinical Expertise, Mini-Assessed Clinical Encounter, Mini-Peer Assessment Tool, Direct Observations of Procedural Skills, Patient Satisfaction Questionnaires, Case Conference, and Journal Club Presentation) were piloted, either singly or in combination, on 16 sites, with 600 psychiatric trainees. RESULTS: Consultant psychiatrists carried out most of the assessments. Case-Based Discussion was the most popular, and high levels of correlation were obtained across several assessment tools. CONCLUSION: There is evidence that with suitable training of assessors and trainees, WPBAs can be introduced and are feasible in assessing some competencies.

Information sources used by the suicidal to inform choice of method.

BACKGROUND: Choice of suicide method strongly influences the outcome of an attempt. Public knowledge of possible methods is an important but less frequently considered aspect of the accessibility of suicide. This qualitative study explored the sources of information shaping the near-fatal suicide attempts of 22 individuals. METHODS: Respondents were recruited from nine hospitals in England. Semi-structured interviews were conducted to gain detailed narratives of the planning of the suicide attempt. Interviews were recorded, transcribed, then subjected to thematic analysis utilising constant comparison techniques. RESULTS: Information sources discussed most frequently were television, news stories, the Internet, and previous self-harm. Others were professional resources, personal knowledge of others' attempts and information gleaned from healthcare professionals. Many respondents reported seeing media portrayals or reports of suicide, which had contributed to their awareness of suicide methods. Several provided examples of direct imitation. Some had deliberately sought information about methods when planning their attempt--mostly from the Internet. Past experience was used to identify 'best' methods and perfect implementation. LIMITATIONS: The frequency with which sources of information are 'used' by particular groups and their relative import cannot be inferred from a qualitative sample. Near-fatal cases may differ from completed suicides. CONCLUSIONS: The media is an important contributor to the cognitive availability of suicide in society and could be used for prevention through carefully crafted portrayals of suicide designed to generate negative social perceptions of popular methods. Understanding of how sources of information can influence perceptions of suicide could inform the content of clinical conversations with patients.

Factors influencing the decision to use hanging as a method of suicide: qualitative study.

BACKGROUND: Hanging is the most frequently used method of suicide in the UK and has high case fatality (>70%). AIMS: To explore factors influencing the decision to use hanging. METHOD: Semi-structured qualitative interviews with 12 men and 10 women who had survived a near-fatal suicide attempt. Eight respondents had attempted hanging. Data were analysed thematically and with constant comparison. RESULTS: Hanging was adopted or contemplated for two main reasons: the anticipated nature of a death from hanging; and accessibility. Those favouring hanging anticipated a certain, rapid and painless death with little awareness of dying and believed it was a 'clean' method that would not damage the body or leave harrowing images for others. Materials for hanging were easily accessed and respondents considered it 'simple' to perform without the need for planning or technical knowledge. Hanging was thus seen as the 'quickest' and 'easiest' method with few barriers to completion and sometimes adopted despite not being a first choice. Respondents who rejected hanging recognised it could be slow, painful and 'messy', and thought technical knowledge was needed for implementation. CONCLUSIONS: Prevention strategies should focus on countering perceptions of hanging as a clean, painless and rapid method that is easily implemented. However, care is needed in the delivery of such messages as some individuals could gain information that might facilitate fatal implementation. Detailed research needs to focus on developing and evaluating interventions that can manage this tension.