Life is better but not without challenges: experiences following discharge from community-based residential mental health rehabilitation-a qualitative content analysis.

PURPOSE: Community-based residential mental health rehabilitation units for people experiencing severe and persistent mental illness are increasingly available in Australia. Research completed 20 years ago suggested that people leaving these services often experienced impoverished social lives and other challenges in the community. It is unclear whether contemporary consumers experience similar difficulties. This qualitative study explored contemporary consumers' experiences after leaving community-based residential services. METHODS: An inductive qualitative content analysis of individual interviews was completed with consumers 12-18 months following discharge from three community care units (CCUs) in Queensland, Australia. The interview schedule explored three questions: (1) What does life look like after leaving the CCU, (2) Has the CCU impacted their life, and (3) How could the CCU experience be improved? A convenience sample was used, with sampling continuing until thematic saturation was achieved. A member of the research team who had relevant lived experience actively supported the analysis and interpretation. RESULTS: Seventeen interviews were completed. Three themes were identified: 'life is better but not without challenges', 'the CCU helps you get ready to go out into the world', and 'strict rules are important but rigid expectations can be hard; things could be better'. CONCLUSION: Consumers reflected positively on their lives post-discharge from a community-based residential rehabilitation unit and viewed the service as having supported improvements in their lives. The findings suggest the appropriateness of optimism about the possibility of sustained improvements in quality of life after leaving community-based transitional residential rehabilitation support.

Staff Experiences of Integrating Peer Support Workers and Clinical Staff in Community-Based Residential Mental Health Rehabilitation: A Pragmatic Grounded Theory Analysis.

Mental health services are increasingly incorporating the views and expertise of people with a lived experience of mental illness in service delivery. A novel approach to this is the 'integrated staffing model' being trialled at two Australian public residential mental health rehabilitation services (Community Care Units, CCUs) where peer support workers (PSWs) occupy the majority of staff roles and work alongside clinicians. Semi-structured interviews were completed with fifteen staff 12-to-18-months after service commencement. Transcripts were analysed following principles of grounded theory analysis. Key emergent themes were: (1) recovery is a deeply personal and non-linear process; (2) The CCU as a transitional learning environment; (3) the integrated staffing model facilitates an effective rehabilitation team; and (4) coming together under the integrated staffing model required a steep learning curve. The findings suggest that the integrated staffing approach may provide a pathway to facilitate the meaningful inclusion of PSWs in rehabilitation settings.

Suicide risk assessment in a large public mental health service: do suicide risk classifications identify those at risk?

INTRODUCTION: Risk assessment tools are routinely used to identify patients at high risk. There is increasing evidence that these tools may not be sufficiently accurate to determine the risk of suicide of people, particularly those being treated in community mental health settings. METHODS: An outcome analysis for case serials of people who died by suicide between January 2014 and December 2016 and had contact with a public mental health service within 31 days prior to their death. RESULTS: Of the 68 people who had contact, 70.5% had a formal risk assessment. Seventy-five per cent were classified as low risk of suicide. None were identified as being at high risk. While individual risk factors were identified, these did not allow to differentiate between patients classified as low or medium. DISCUSSION: Risk categorisation contributes little to patient safety. Given the dynamic nature of suicide risk, a risk assessment should focus on modifiable risk factors and safety planning rather than risk prediction. CONCLUSION: The prediction value of suicide risk assessment tools is limited. The risk classifications of high, medium or low could become the basis of denying necessary treatment to many and delivering unnecessary treatment to some and should not be used for care allocation.

Psychosocial and lifestyle predictors of distress and well-being in people with mental illness during the COVID-19 pandemic.

OBJECTIVES: People with mental illness may be vulnerable to psychological distress and reduced well-being during the COVID-19 pandemic. The aim of this study was to assess psychosocial and lifestyle predictors of distress and well-being in people with mental illness during the pandemic. METHOD: People with mental illness who participated in an exercise programme prior to the pandemic were invited to complete surveys about mental health and lifestyle corresponding to before and during the pandemic. RESULTS: Social support reduced, alcohol intake increased, and sleep quality and diet worsened during the pandemic, contributing to distress. Psychological distress was associated with the two or more mental illnesses, and negatively associated with having a physical disease. Better diet appeared to protect against increases in distress; loneliness hindered improvements in well-being. CONCLUSIONS: Healthy lifestyle programmes designed to improve social connection may improve health for people with mental illnesses during and after the COVID-19 pandemic.

LOVE in the time of Covid-19: a brief mental health intervention to overcome loneliness.

OBJECTIVE: The coronavirus disease 2019 outbreak and its containment through public health strategies has resulted in a parallel pandemic of psychological distress. Increased loneliness and social isolation are associated with adverse health outcomes, yet there is a gap in brief interventions that specifically target loneliness. This article introduces a brief intervention to strengthen connectedness, LOVE. In a systematic way, this solution-focused approach encourages openness and sharing of current struggles with the existing circle of support. There are four steps in LOVE: List people in one's life, Organise them on the helpfulness-availability matrix, Verify what they know to map them onto circles of trust and Engage them through self-disclosure. CONCLUSION: The article details each concept, its importance, the pragmatics involved and top tips to guide practice. The memorable acronym provides logical sequence and structure. It is time efficient in training and delivery, with no former mental health knowledge required so there is potential for wide application. It facilitates collaboration between health professionals and people in distress and promotes empowerment and self-resilience. Adapted from the safety planning component of PROTECT, a pre-existing suicide prevention framework, LOVE has to be fine-tuned as a brief intervention in the wider context of the pandemic.

Life in 90 words: opportunities for person-centred care amidst COVID-19.

OBJECTIVE: Coronavirus disease 2019 and the consequent public health and social distancing measures significantly impacted on service continuity for mental health patients. This article reports on contingency planning initiative in the Australian public sector. METHODS: Ninety-word care synopses were developed for each patient. These formed the basis for guided conversations between case managers and consultant psychiatrists to ensure safe service provision and retain a person-centred focus amidst the threat of major staffing shortfalls. RESULTS: This process identified vulnerable patient groups with specific communication needs and those most at risk through service contraction. The challenges and opportunities for promoting safety and self-management through proactive telehealth came up repeatedly. The guided conversations also raised awareness of the shared experience between patients and professionals of coronavirus disease 2019. CONCLUSION: There is a parallel pandemic of anxiety which creates a unique opportunity to connect at a human level.

Preferences of people with mental illness for engaging in exercise programs under COVID-19 restrictions.

OBJECTIVES: People with mental illness may be vulnerable to decline in mental health and reduced physical activity because of the COVID-19 pandemic and associated restrictions. The aim of this study was to inform the design of physical activity interventions for implementation under these conditions to improve/maintain well-being and physical activity in this population. METHODS: People with mental illness who had participated in a physical activity program prior to the pandemic were invited to complete a survey about the impact of COVID-19 on mental health and physical activity and their preferences for engaging in a physical activity program under pandemic-related restrictions. RESULTS: More than half the 59 respondents reported worse mental health and lower physical activity during the pandemic. The preferred format for a physical activity program was one-on-one exercise instruction in-person in a park. Program components endorsed as helpful included incentivization, provision of exercise equipment and fitness devices, and daily exercise programs. About a third of the participants reported limitations in using technology for a physical activity program. CONCLUSIONS: In-person exercise support is preferred by people with mental illnesses during pandemic-related restrictions. Enablement strategies such as providing equipment and self-monitoring devices should be utilized; assistance may be needed to incorporate the use of technology in exercise programs.

How health care systems let our patients down: a systematic review into suicide deaths.

PURPOSE: To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. DATA SOURCES: A systematic narrative meta-synthesis using the PRISMA methodology was conducted. STUDY SELECTION: All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded. DATA EXTRACTION: Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set. RESULTS OF DATA SYNTHESIS: Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients. CONCLUSIONS: There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.

Single session work: Implementing brief intervention as routine practice in an acute care mental health assessment service.

OBJECTIVES:: The study describes the implementation and adaptation of a brief intervention model as routine clinical practice in an acute care service. METHODS:: An action research process informed the evaluation and design of the intervention. RESULTS:: The model's theoretical framework enhanced clinical practice and benefited consumers, though it was too rigid to be implemented in an acute care setting, so was adapted to suit this environment. CONCLUSIONS:: This paper highlights the value in realigning practice with fundamental engagement principles to improve practice outcomes.

The language we use - the effect of writing mental health care plans in the first person.

OBJECTIVE: This study describes the impact of Motivational Aftercare Planning (MAP) - an intervention to increase consumer/clinician collaboration on the content of mental health recovery plans. The intervention focussed on enhancing existing discharge processes in psychiatric inpatient wards and supporting nursing staff in using motivational interviewing techniques to facilitate the completion of these plans. METHODS: We conducted a qualitative thematic content analysis of the recovery plans completed throughout the study ( n = 110). Chi-squared tests were then used to compare the occurrence of themes and content identified in recovery plans pre and post the intervention ( n = 55). RESULTS: The thematic content of the recovery plans shifted in focus following the intervention, with a change from third to first person language. Those completed prior to the intervention generally mentioned: decreasing symptoms of mental illness; acceptance of the illness; achieving clinical stability; risk management and treatment compliance. The recovery plans completed after the intervention focussed on: general wellness; participate in meaningful activities; community life; social roles and connections with others. CONCLUSIONS: This study demonstrated that a simple time-limited, facilitated intervention resulted in a change of thematic content in recovery plans. The use of these plans and its effect on care planning will need further evaluation.

The importance of safety, agency and control during involuntary mental health admissions.

BACKGROUND: Constructs such as personal recovery, patient engagement and consumer involvement are central in mental health care delivery. These approaches emphasise the importance of empowerment and choice. AIMS: Under some circumstances Involuntary Treatment Orders (ITO) allow a person to be treated for a mental illness without their consent. This study explores the tensions between the principles of empowerment and control and involuntary treatment. METHODS: Twenty-five involuntary inpatients of a major teaching hospital were interviewed about their experiences of being placed under an ITO. The interviews were analysed thematically. RESULTS: Being able to have some sense of agency and re-asserting personal control are critical components of an involuntary mental health admission. Participants wanted information about their treatment, the ITO process and their environment. They also spoke about the importance of a space where they felt safe from themselves and others to make sense of the experience. CONCLUSIONS: This study suggests that for coercive treatment to aid, rather than disrupt recovery, treatment services need to focus on: the provision of rights; the creation of a sense of safety; establishing supportive relationships; carrying hope and finding ways to foster a strong sense of agency and empowerment.

Measuring recovery-oriented rehabilitation language in clinical documentation to enhance recovery-oriented practice.

BACKGROUND: Mental health services are encouraged to use language consistent with principles of recovery-oriented practice. This study presents a novel approach for identifying whether clinical documentation contains recovery-oriented rehabilitation language, and evaluates an intervention to improve the language used within a community-based rehabilitation team. AIMS: This is a pilot study of training to enhance recovery-oriented rehabilitation language written in care review summaries, as measured through a text-based analysis of language used in mental health clinical documentation. METHOD: Eleven case managers participated in a programme that included instruction in recovery-oriented rehabilitation principles. Outcomes were measured with automated textual analysis of clinical documentation, using a custom-built dictionary of rehabilitation-consistent, person-centred and pejorative terms. Automated analyses were run on Konstanz Information Miner (KNIME), an open-source data analytics platform. Differences in the frequency of term categories in 50 pre-training and 77 post-training documents were analysed with inferential statistics. RESULTS: The average percentage of sentences with recovery-oriented rehabilitation terms increased from 37% before the intervention to 48% afterward, a relative increase of 28% (P < 0.001). There was no significant change in use of person-centred or pejorative terms, possibly because of a relatively high frequency of person-centred language (22% of sentences) and low use of pejorative language (2.3% of sentences) at baseline. CONCLUSIONS: This computer-driven textual analysis method identified improvements in recovery-oriented rehabilitation language following training. Our study suggests that brief interventions can affect the language of clinical documentation, and that automated text-analysis may represent a promising approach for rapidly assessing recovery-oriented rehabilitation language in mental health services.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients.

OBJECTIVE: A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention. METHODS: A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact. RESULTS: ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention. CONCLUSIONS: Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

Heard, known, and safe in general practice? An interview study with patients with severe and persistent mental illness.

BACKGROUND: Although GPs provide care to many patients with severe and persistent mental illness, the role and skillset of the GP in this space are contested. Patients are less satisfied with GP care of mental health than physical health issues. AIM: To explore patient expectations and experiences of GP roles in their mental health, and identify opportunities for improving mental health care in general practice. DESIGN & SETTING: Patient participants were recruited from community mental health clinics in Brisbane, Australia. METHOD: Individual semi-structured interviews were conducted with a convenience sample of patients. Interviews were audio-recorded and transcribed professionally. The authors conducted an inductive thematic analysis, attending to participant vulnerability and reflexivity. RESULTS: Sixteen interviews were conducted by one author (RW), with an average duration of 29 minutes. Three overarching themes were identified: being heard, being known, and being safe. Participants greatly valued 'good GPs' who were able to detect early signs of relapse, and with whom they came to feel heard, known, and safe over time. Experiences of perfunctory, hurried care and avoidance of mental health issues were also reported. Many participants were uncertain whether GP training in mental health was sufficient to keep them safe. Patients may suspect GPs who predominantly engage with their physical health to have negative attitudes to mental illness. CONCLUSION: Some GPs play central roles in patients' mental health care. Barriers for others need further exploration, and may include time, confidence, and/or expertise. Findings challenge GPs to engage more actively and effectively with these patients in their general practice consultations.

A Shelter in the Storm - Acceptability and Feasibility of a Brief Clinical Intervention for Suicidal Crisis.

Background: People attending the emergency department (ED) for suicidal crisis are at significantly higher risk of taking their own lives in the week following discharge. Aims: We aimed to evaluate the acceptability and feasibility of implementing a brief clinical aftercare intervention provided through Allied Health Brief Therapies (AHBTs) Clinics. Method: Consecutive referrals (n = 149) to the clinics following assessment in the ED for suicidal crisis formed the study group. This article details participant engagement and retention, service provision, therapeutic alliance, and participant satisfaction with the program. Suicidal ideation and ED utilization 3 months pre-/postintervention were used to assess short-term impact. Results: The study supports the feasibility of implementing a brief aftercare intervention for those presenting to the ED for suicidal crisis. High rates of therapeutic alliance and satisfaction with the clinic intervention were reported by participants. Impact assessments pointed to a significant reduction in both suicidal ideation and ED utilization following the intervention. Limitations: A substantial number of participants had missing follow-up data. Given this and the absence of a control group, findings must be interpreted with caution. Conclusion: The study supports the acceptability and feasibility of implementing AHBT Clinics as a potential adjunct in the aftercare of people in suicidal crisis.

Impact of a new specialist alcohol and drug brief intervention service model integrated into the emergency department: An interrupted time series analysis.

OBJECTIVE: To describe and examine the impact of a new specialist drug and alcohol brief intervention team (DABIT) model integrated into the ED on the identification of individuals at risk of future alcohol and other drug (AOD)-related harm. A cost-outcome analysis was conducted to assess the impact on costs per referral. METHODS: An interrupted time series analysis examined the changes in number of referrals following the implementation of the DABIT model over 2 years (January 2015-December 2016) within a large 436-bed public hospital. The primary outcome of interest was the number of AOD-related referrals per month identified following ED presentations. The independent variables were: time (measured in months), implementation periods (pre-implementation; a transition period of adjustment during which the new DABIT model of care was developed; post-implementation period with a fully operational DABIT model); and the number of full-time equivalent staff per month to account for the increase in labour productivity. In a second time series analysis, the outcome was cost per referral per month. RESULTS: After controlling for changes in labour productivity, the number of referrals was significantly higher following the implementation of the DABIT model when compared to those during the pre-implementation and transition periods. Costs were significantly lower following DABIT implementation resulting in $1096 net cost savings per referral. CONCLUSIONS: Integration of a specialist brief intervention AOD model to support ED care may increase uptake of specialist AOD treatment and could be beneficial from an economic efficiency viewpoint.

Subjective Experiences of Mental Health Crisis Care in Emergency Departments: A Narrative Review of the Qualitative Literature.

Mental health presentations to the emergency department (ED) have increased, and the emergency department has become the initial contact point for people in a mental health crisis. However, there is mounting evidence that the ED is not appropriate nor effective in responding to people in mental health crises. Insufficient attention has been paid to the subjective experience of people seeking support during a mental health crisis. This review aims to describe the qualitative literature involving the subjective experiences of people presenting to the ED during a mental health crisis. The method was guided by Arksey and O'Malley's framework for scoping studies and included keyword searches of PsycINFO, CINAHL, Medline and Embase. A narrative analysis, drawing on the visual tool of journey mapping, was applied to summarise the findings. Twenty-three studies were included. The findings represent the experience of accessing EDs, through to the impact of treatment. The review found points of opportunity that improve people's experiences and characteristics associated with negative experiences. The findings highlight the predominance and impact of negative experiences of the ED and the incongruence between the expectations of people presenting to the ED and the experience of treatment.

Consumer experiences of community-based residential mental health rehabilitation for severe and persistent mental illness: A pragmatic grounded theory analysis.

Semi-structured interviews were used to explore the consumer experience of community-based residential mental health rehabilitation support at Community Care Units in Australia. These clinical services provide recovery-oriented residential rehabilitation to people affected by severe and persistent mental illness. Typically, nurses occupy the majority of staff roles. However, two of the three sites in the study were trialling a novel integrated staffing model where the majority of staff were people with a lived experience of mental illness employed as peer support workers (PSWs). The interviews explored consumers' experiences of care 12-18 months after admission. Fifteen interviews were completed with an independent interviewer. Most participants were diagnosed with schizophrenia or a related psychotic disorder. The analysis followed a pragmatic approach to grounded theory. Consumers viewed the CCU favourably, emphasizing the value of the relationships formed with staff and co-residents. No major differences in consumers' experience under the traditional versus integrated staffing models were identified; however, those from the integrated staffing model sites valued the contributions of the peer support workers. The understanding of the consumer experience emerging through this study aligned with their expectations of the service at the time of commencement.

Rapid cytopathic effects of Clostridium perfringens beta-toxin on porcine endothelial cells.

Clostridium perfringens type C isolates cause fatal, segmental necro-hemorrhagic enteritis in animals and humans. Typically, acute intestinal lesions result from extensive mucosal necrosis and hemorrhage in the proximal jejunum. These lesions are frequently accompanied by microvascular thrombosis in affected intestinal segments. In previous studies we demonstrated that there is endothelial localization of C. perfringens type C beta-toxin (CPB) in acute lesions of necrotizing enteritis. This led us to hypothesize that CPB contributes to vascular necrosis by directly damaging endothelial cells. By performing additional immunohistochemical studies using spontaneously diseased piglets, we confirmed that CPB binds to the endothelial lining of vessels showing early signs of thrombosis. To investigate whether CPB can disrupt the endothelium, we exposed primary porcine aortic endothelial cells to C. perfringens type C culture supernatants and recombinant CPB. Both treatments rapidly induced disruption of the actin cytoskeleton, cell border retraction, and cell shrinkage, leading to destruction of the endothelial monolayer in vitro. These effects were followed by cell death. Cytopathic and cytotoxic effects were inhibited by neutralization of CPB. Taken together, our results suggest that CPB-induced disruption of endothelial cells may contribute to the pathogenesis of C. perfringens type C enteritis.