Mental health related stigma in Romania: systematic review and narrative synthesis.

BACKGROUND: Stigma related to mental illness is increasingly and more effectively addressed. Although more research is being conducted, there is relatively little from low and middle-income countries, with former Soviet bloc countries identified as a particular contributor to this evidence gap. Romania struggles with mental health stigma at many levels. The aim of this review was to bring together all relevant data regarding stigma and discrimination related to mental illness as well as actions to address these problems in Romania in order to prioritise further stigma research and identify priority targets for stigma reduction. METHODS: A systematic literature search was conducted in three online databases and grey literature. After the analysis of full manuscripts, four were excluded based on lack of relevance or incomplete data reporting. Quality assessment was performed for included studies using the Mixed Methods Appraisal Tool (MMAT) and the narrative was synthesized based on the research questions. RESULTS: The review included fifteen studies, the majority having a cross-sectional design. Stigma related to mental illness in Romania, has an impact on help-seeking attitudes and behaviours, workplace environment and social relationships of people with mental health problems. Negative stereotypes are maintained and validated by mass media reports. Significant stigma in healthcare and mental care settings has also been observed. Self-stigma was less frequently reported than public stigma. Despite a few stigma reduction actions, no rigorous evaluation of content, delivery and effectiveness has been conducted and no empirical evidence has been published. CONCLUSIONS: Based on this review, three lines of action are recommended in Romania. Increase research concerning stigma in healthcare and mental care settings and use behavioural outcomes. Develop and deliver evidence-based tailored interventions to reduce stigma in identified priority subgroups of the population and ensure rigorous evaluation and scientific dissemination. Elaborate guidelines for working with community stigma and advocate for structural changes.

Advance Statements for Black African and Caribbean people (AdStAC): protocol for an implementation study.

BACKGROUND: The UK government committed to legislating for Advance Choice Documents/Advance Statements (ACD/AS) following their recommendation by the Independent Review of the MHA (2018). ACDs/AS are yet to be implemented in routine practice despite evidence and high demand; they are associated with improved therapeutic relationships and a reduction (25%, RR 0.75, CI 0.61-0.93) in compulsory psychiatric admission. Barriers to their implementation are well documented, ranging from low knowledge levels to logistical challenges in accessing the content during episodes of acute care. In the UK this is an issue for Black people, who experience detention rates disproportionately (over three times) higher than those of White British people and have poorer care experiences and outcomes. ACDs/AS allow for Black people to have their concerns heard by mental health professionals in a care system where they often feel their views are ignored. AdStAC aims to improve Black service users' experiences in mental health services in South London by co-producing and testing an ACD/AS implementation resource with Black service users, mental health professionals and carers/supporters of Black service users. METHODS/DESIGN: The study will take place in South London, England over three phases: 1) formative work through stakeholder workshops; 2) co-production of resources through a consensus development exercise and working groups; and 3) testing of the resources using quality improvement (QI) methods. A lived experience advisory group, staff advisory group and project steering committee will support the study throughout. The implementation resources will comprise: advance choice document/advance statement (ACD/AS) documentation, stakeholder trainings, a manual for mental health professionals to facilitate the processes of creating and revising advance statements, and informatics development. DISCUSSION: The implementation resources will help increase the likelihood of the new mental health legislation in England being implemented effectively; through aligning evidence-based medicine, policy and law to effectively provide positive clinical, social and financial outcomes for Black people, the National Health Service (NHS) and wider society. This study will likely benefit a wider group of people with severe mental illness, as when marginalised groups who are least engaged, can be supported with these strategies, then the strategies are likely to work for others.

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

INTRODUCTION: Patient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community-based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community-based mental health care. METHODS: A narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community-based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science. RESULTS: Amongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long-term care journeys and establishing what constitutes a 'preventable' safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards. CONCLUSION: We propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of 'safety intelligence', to advance how safety is conceived and addressed within community mental health care. PATIENT AND PUBLIC CONTRIBUTION: This paper was part of a larger research project aimed at understanding and improving patient safety in community-based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community-based mental health services for working-age adults, who advised on key questioning priorities.

Experiences of Every Mind Matters, Public Health England's adult mental health literacy campaign: a qualitative interview study.

BACKGROUND: Every Mind Matters (EMM) is a publicly funded health campaign, launched in England in 2019, to equip adults to look after their mental health, and that of others, by offering online information about common problems: anxiety, low mood, sleep, and stress. This study is one component of an independent evaluation of EMM conducted by the NIHR Mental Health Policy Research Unit. Its aim is to explore individuals' experiences of the EMM campaign and website. METHODS: Four researchers, including three with lived experience of using mental health services, conducted 20, one-off, semi-structured, online interviews with a range of adult participants, including a sample of EMM users and a purposively recruited sub-sample known to have severe or long-term mental health conditions. A codebook thematic analysis was undertaken, and four main themes were identified. FINDINGS: There was an expectation from the name Every Mind Matters that its advice would address everyone. Almost all participants had experience of mental distress and looked to EMM for help with a current problem for themselves. All participants were complimentary about the EMM website and found it to be user-friendly (theme 1) and personalised (theme 2) especially the interactive feature Your Mind Plan quiz which responds with suggested actions to improve wellbeing and follows up with reminder emails. A few participants found the website information and/or Mind Plan suggestions to be life changing. Some participants wanted EMM to better acknowledge the contexts in which they live (theme 3) such as the limitations of health conditions and health services, and difficulties of crowded housing, social policy, and climate change. Many participants would like EMM to do more (theme 4), offer more interactivity, more choice, more information about available treatments, and more stratified advice to cover more severe mental health conditions. CONCLUSION: EMM is available to all, including people with common or severe mental disorders. In the context of overwhelmed mental health services, people with severe mental illness expect more from EMM than advice about common problems. EMM could build on its success by extending its remit to address a wider range of needs so that everyone is included.

The Every Mind Matters campaign: changes in mental health literacy and its associations with campaign awareness.

BACKGROUND: The aim of this study is to investigate the effects on population level mental health literacy (MHL) of Every Mind Matters over 30 months following campaign launch. METHODS: To observe changes in MHL over time, we conducted regression analyses on a nationally representative, repeated cross-sectional dataset of nine survey waves from September 2019 to March 2022 and an individual participant data meta-analysis with data from October 2019 to March 2021 to examine the association between campaign awareness and the outcomes. RESULTS: There were small improvements in knowledge of management of stress, depression and anxiety, mental health vigilance, sleep literacy and psychological wellbeing self-efficacy from September 2019 to March 2020 and a deterioration in most MHL outcomes from March 2020 compared with September 2019. Campaign awareness was positively associated with symptom management of depression and anxiety, help seeking self-efficacy, stigma related to mental disorders and mental health vigilance. CONCLUSIONS: There is little evidence that the campaign improved MHL in the general population beyond March 2020. Those who were aware of the campaign may have benefitted from its resources.

Is the self-reporting of mental health problems sensitive to public stigma towards mental illness? A comparison of time trends across English regions (2009-19).

PURPOSE: The prevalence of mental health problems has rapidly increased over time. The extent to which this captures changes in self-reporting due to decreasing stigma is unclear. We explore this by comparing time trends in mental health and stigma-related indicators across English regions. METHODS: We produced annual estimates of self-reported mental disorders (SRMDs) across waves of the Health Survey for England (2009-18, n = 78,226) and three stigma-related indicators (knowledge, attitudes, and intended behaviour) across waves of the Attitudes Towards Mental Illness survey (2009-19, n = 17,287). Differences in trends were tested across nine Government Office Regions using linear models, adjusting for age, sex, ethnicity, marital status, and social class. RESULTS: In 2009, SRMDs did not vary by region (p = 0.916), whereas stigma-related indicators did (p < 0.001), with London having the highest level of stigma and the North East having lowest level of stigma. Between 2009 and 2018, the prevalence of SRMDs increased from 4.3 to 9.1%. SRMDs increased and stigma-related indicators improved at different rates across regions over time (SRMDs p = 0.024; stigma-related indicators p < 0.001). London reported the lowest increase in SRMDs (+ 0.3 percentage point per year) yet among the largest improvements in attitudes and intended behaviour across regions. CONCLUSIONS: Improvements in attitudes towards mental illness did not mirror changes in self-reported mental health problems across English regions over the past decade. The findings do not support the argument that changes in public stigma, at least when defined at this regional scale, have been driving the increase in self-reported mental health indicators in recent years.

Pilot study of a manualised mental health awareness and stigma reduction intervention for Black faith communities in the UK: ON TRAC project.

BACKGROUND: Building partnerships between mental health services and Black faith communities to co-produce culturally tailored interventions is an essential step towards improving access to services and reducing stigma among the Black population. Given that Black faith organisations are considered a primary source of emotional and psychological support they are well positioned as 'gatekeepers' for services, to overcome barriers to engagement and build trusting relationships with the Black community. The aim of this paper is to pilot a manualised mental health awareness and stigma reduction intervention for Black faith communities in the UK, and to make an initial assessment of feasibility, acceptability and outcomes. METHODS: This study employed a mixed methods pre-post-design, based upon the Medical Research Council Framework (MRC) for complex interventions, and the Implementation Science Research Development. RESULTS: The qualitative assessments indicate that the intervention was found overall to be acceptable and feasible to the Black faith community population. This pilot study did not find statistically significant changes for the Mental Health Knowledge schedule (MAKS), Reported and Intended Behaviour Scale (RIBS), intended help-seeking or willingness to disclose (Attitudes to Mental Illness Survey) measures. However, the direction of all the non-significant changes in these measures suggests positive changes in mental health knowledge, a reduction in participants' desire for social distance, and greater willingness to disclose personal experiences of mental health problems. A statistically significant improvement in the Community Attitudes towards Mental Illness (CAMI) scale results indicated a lower level of stigmatising attitudes towards people with lived experience of mental health conditions (PWLE), and an increase in tolerance and support towards PWLE after the intervention. Significant improvement in the willingness to disclose measure suggests increased preparedness to seek help amongst participants, a lesser desire for social distance, and greater willingness to engage with PWLE after the intervention. Three key themes, including 9 subthemes were identified from the qualitative data analysis: (i) initial implementation and intention to adopt; (ii) perceived suitability and usefulness of intervention to address cultural issues relating to mental health in the Black community; and (iii) strengthening the capacity of faith leaders. CONCLUSIONS: This ON TRAC pilot study shows that the intervention was feasible and acceptable, and that it has promising positive impacts and next requires larger scale evaluation. These results demonstrate that the intervention was a culturally acceptable way to potentially increase mental health awareness and reduce stigma in Black faith communities. TRIAL REGISTRATION: ISRCTN12253092.

Evidence-based Recovery Colleges: developing a typology based on organisational characteristics, fidelity and funding.

PURPOSE: Recovery Colleges (RCs) have been implemented across England with wide variation in organisational characteristics. The purpose of this study is to describe RCs across England in terms of organisational and student characteristics, fidelity and annual spending, to generate a RC typology based on characteristics and to explore the relationship between characteristics and fidelity. METHODS: All RC in England meeting criteria on recovery orientation, coproduction and adult learning were included. Managers completed a survey capturing characteristics, fidelity and budget. Hierarchical cluster analysis was conducted to identify common groupings and generate an RC typology. RESULTS: Participants comprised 63 (72%) of 88 RC in England. Fidelity scores were high (median 11, IQR 9-13). Both NHS and strengths-focussed RCs were associated with higher fidelity. The median annual budget was £200,000 (IQR £127,000-£300,000) per RC. The median cost per student was £518 (IQR £275-£840), cost per course designed was £5,556 (IQR £3,000-£9,416) and per course run was £1,510 (IQR £682-£3,030). The total annual budget across England for RCs is an estimated £17.6 m including £13.4 m from NHS budgets, with 11,000 courses delivered to 45,500 students. CONCLUSION: Although the majority of RCs had high levels of fidelity, there were sufficiently pronounced differences in other key characteristics to generate a typology of RCs. This typology might prove important for understanding student outcomes and how they are achieved and for commissioning decisions. Staffing and co-producing new courses are key drivers of spending. The estimated budget for RCs was less than 1% of NHS mental health spending.

How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study.

BACKGROUND: Return on Investment (ROI), whereby the ratio of costs to benefits is assessed, is encouraged in-order to justify the value of Quality Improvement (QI) programmes. We previously performed a literature review to develop a ROI conceptual framework for QI programmes. We concluded that, QI-ROI is conceptualised as any monetary and non-monetary benefit. In the current study, we explored if this finding is shared by mental healthcare leaders. We also investigated the stability of this conceptualisation against influencing factors and potential for disinvestment. METHODS: We performed qualitative interviews with leaders in an NHS mental health organisation. There were 16 participants: nine board members and seven senior leaders. The interviews were held online via Microsoft Teams and lasted an hour on average. We performed deductive-inductive analysis to seek data from our initial ROI framework and any new data. RESULTS: We found that in mental healthcare, QI-ROI is also conceptualised as any valued monetary and non-monetary benefits. There was a strong emphasis on benefits to external partners and a de-emphasis of benefit monetisation. This conceptualisation was influenced by the 1) perceived mandates to improve quality and manage scarce resources, 2) expectations from QI, 3) health and social care values, 4) ambiguity over expectations, and 5) uncertainty over outcomes. Uncertainty, ambiguity, and potential for disinvestment posed a threat to the stability of this conceptualisation but did not ultimately change it. Health and social care values supported maintaining the QI-ROI as any benefit, with a focus on patients and staff outcomes. Socio-political desires to improve quality were strong drivers for QI investment. CONCLUSION: Mental healthcare leaders primarily conceptualise QI-ROI as any valued benefit. The inclusion of externalised outcomes which are hard to attribute may be challenging. However, mental healthcare services do collaborate with external partners. The de-emphases of benefit monetisation may also be controversial due to the need for financial accountability. Mental healthcare leaders recognise the importance of efficiency savings. However, they raised concerns over the legitimacy and utility of traditional ROI as a tool for assessing QI value. Further research is needed to bring more clarity on these aspects of the QI-ROI concept.

Anti-stigma advocacy for health professionals: a systematic review.

BACKGROUND: Many anti-stigma programs for healthcare workers already exist however there is less research on the effectiveness of training in skills for health professionals to counter stigma and its impacts on patients. AIMS: The objective of this study was to examine the theory base, content, delivery, and outcomes of interventions for healthcare professionals which aim to equip them with knowledge and skills to aid patients to mitigate stigma and discrimination and their health impacts. METHODS: Five electronic databases and grey literature were searched. Data were screened by two independent reviewers, conflicts were discussed. Quality appraisal was realized using the ICROMS tool. A narrative synthesis was carried out. RESULTS: The final number of studies was 41. In terms of theory base, there are three strands - responsibility as part of the professional role, correction of wrongful practices, and collaboration with local communities. Content focusses either on specific groups experiencing health-related stigma or health advocacy in general. CONCLUSIONS: Findings suggest programs should link definitions of stigma to the role of the professional. They should be developed following a situational analysis and include people with lived experience. Training should use interactive delivery methods. Evaluation should include follow-up times that allow examination of behavioural change. PROSPERO, ID: CRD42020212527.

The effectiveness and design of informed choice tools for people with severe mental illness: a systematic review.

BACKGROUND: People with severe mental illness (SMI) report difficulty in making health-related decisions. Informed choice tools are designed to guide individuals through a decision-making process. AIMS: To determine the effectiveness of these tools for people with SMI and to identify what methods and processes may contribute to effectiveness. METHOD: A systematic electronic search was conducted for studies published between 1996 and January 2018. The search was updated in March 2020. Studies of any design reporting the development or evaluation of any informed choice tool for people with SMI were considered. A structured, narrative synthesis was conducted. RESULTS: Ten articles describing four tools were identified. Tools were designed to assist with decision-making around bipolar treatment, smoking cessation and disclosure of mental illness in employment situations. Positive changes in decisional conflict, stage of change, knowledge and self-efficacy were reported for two tools, though insufficient data exists for definitive conclusions of effectiveness. Feedback from service users and attention to readability appeared key. CONCLUSIONS: The evidence base for informed choice tools for people with SMI is limited. Such tools should be developed in stages and include the views of people with SMI at each phase; readability should be considered, and a theoretical framework should be used to facilitate process evaluation.

Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis.

BACKGROUND: Poor social circumstances can induce, exacerbate and prolong symptoms of mental health conditions, while having a mental health condition can also lead to worse social outcomes. Many people with mental health conditions prioritise improvement in social and functional outcomes over reduction in clinical symptoms. Interventions that improve social circumstances in this population should thus be considered a priority for research and policy. METHODS: This rapid evidence synthesis reports on randomised controlled trials of interventions to improve social circumstances across eight social domains (Housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship) in people with mental health conditions. Economic evaluations were also identified. A comprehensive, stepped search approach of the Cochrane library, MEDLINE, Embase, PsycINFO, Web of Science and Scopus was conducted. RESULTS: One systematic review and 102 randomised controlled trials were included. We did not find RCT evidence for interventions to improve family, intimate and caring relationships and only one or two trials for each of improving money and basic needs, victimisation and exploitation, and rights, inclusion and citizenship. Evidence from successful interventions in improving homelessness (Housing First) and employment (Individual Placement and Support) suggests that high-intensity interventions which focus on the desired social outcome and provide comprehensive multidisciplinary support could influence positive change in social circumstances of people with mental health conditions. Objective social isolation could be improved using a range of approaches such as supported socialisation and social skills training but interventions to reduce offending showed few benefits. Studies with cost and cost-effectiveness components were generally supportive of interventions to improve housing and vocational outcomes. More research is needed to ensure that social circumstances accompanied by high risks of further exacerbation of mental health conditions are adequately addressed. CONCLUSIONS: Although there is a large body of literature examining how to support some aspects of life for people with mental health conditions, more high-quality evidence is required in other social domains. Integration into mental health services of interventions targeting social circumstances could significantly improve a number of social outcomes.

Recovery Colleges Characterisation and Testing in England (RECOLLECT): rationale and protocol.

BACKGROUND: Recovery Colleges are a relatively recent initiative within mental health services. The first opened in 2009 in London and since then numbers have grown. They are based on principles of personal recovery in mental health, co-production between people with lived experience of mental health problems and professionals, and adult learning. Student eligibility criteria vary, but all serve people who use mental health services, with empirical evidence of benefit. Previously we developed a Recovery College fidelity measure and a preliminary change model identifying the mechanisms of action and outcomes for this group, which we refer to as service user students. The Recovery Colleges Characterisation and Testing (RECOLLECT) study is a five-year (2020-2025) programme of research in England. The aim of RECOLLECT is to determine Recovery Colleges' effectiveness and cost-effectiveness, and identify organisational influences on fidelity and improvements in mental health outcomes.  METHODS: RECOLLECT comprises i) a national survey of Recovery Colleges, ii) a prospective cohort study to establish the relationship between fidelity, mechanisms of action and psychosocial outcomes, iii) a prospective cohort study to investigate effectiveness and cost-effectiveness, iv) a retrospective cohort study to determine the relationship between Recovery College use and outcomes and mental health service use, and v) organisational case studies to establish the contextual and organisational factors influencing fidelity and outcomes. The programme has been developed with input from individuals who have lived experience of mental health problems. A Lived Experience Advisory Panel will provide input into all stages of the research. DISCUSSION: RECOLLECT will provide the first rigorous evidence on the effectiveness and cost effectiveness of Recovery Colleges in England, to inform their prioritising, commissioning, and running. The validated RECOLLECT multilevel change model will confirm the active components of Recovery Colleges. The fidelity measure and evidence about the fidelity-outcome relationship will provide an empirically-based approach to develop Recovery Colleges, to maximise benefits for students. Findings will be disseminated through the study website (researchintorecovery.com/recollect) and via national and international Recovery College networks to maximise impact, and will shape policy on how Recovery Colleges can help those with mental health problems lead empowered, meaningful and fulfilling lives.

Crisis interventions for adults with borderline personality disorder.

BACKGROUND: People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD. OBJECTIVES: To assess the effects of crisis interventions in adults diagnosed with BPD in any setting. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence.  The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review. AUTHORS' CONCLUSIONS: A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

Exploring the effectiveness of family-based interventions for psychosis in low- and middle-income countries: a systematic review.

PURPOSE: Of the 80% people with psychosis living in low- and middle-income countries (LMICs), up to 90% are left to the care of families. The World Health Organization has recommended the inclusion of families in community-based rehabilitation and while there is evidence of its implementation in LMICs, this has not been reviewed yet. This study aims to describe the key features and implementation strategies of family-based interventions in LMICs, and appraise their effectiveness. METHODS: Included are people with psychosis in LMICs who receive any form of family-based intervention, compared to their usual or absence of treatment, with patient outcome measures. We searched (August 2021) through Embase, MEDLINE, Global Health, PsycInfo, Social Policy and Practice, and Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as from grey literature and hand-searched records. Risk of bias was assessed through the Integrated Quality Criteria for Review of Multiple Study Designs (ICROMS) and Consolidated Health Economic Evaluation Reporting Standards (CHEERS), then analyzed narratively. RESULTS: 27 studies were included from the 5254 records. Psychotherapeutic features, systems approach and task-sharing were key intervention elements. Delivery strategies included preliminary research, sustained family engagement, and cultural adaptation. There were positive health impacts across four outcome domains. CONCLUSION: All studies recommended family-based interventions, with limitations in heterogeneity and 70% of them rated high risk of bias. OTHER: Review was registered in PROSPERO (CRD42021256856). The authors did not receive funding for this research.

Anti-stigma training and positive changes in mental illness stigma outcomes in medical students in ten countries: a mediation analysis on pathways via empathy development and anxiety reduction.

PURPOSE: Studies of mental illness stigma reduction interventions have been criticised for failing to evaluate behavioural outcomes and mechanisms of action. This project evaluates training for medical students entitled 'Responding to Experienced and Anticipated Discrimination' (READ), developed to focus on skills in addition to attitudes and knowledge. We aimed to (i) evaluate the effectiveness of READ with respect to knowledge, attitudes, and clinical communication skills in responding to mental illness-related discrimination, and (ii) investigate whether its potential effectiveness was mediated via empathy or/and intergroup anxiety. METHODS: This is an international multisite non-randomised pre- vs post-controlled study. Eligible medical students were currently undertaking their rotational training in psychiatry. Thirteen sites across ten countries (n = 570) were included in the final analysis. RESULTS: READ was associated with positive changes in knowledge (mean difference 1.35; 95% CI 0.87 to 1.82), attitudes (mean difference - 2.50; 95% CI - 3.54 to - 1.46), skills (odds ratio 2.98; 95% CI 1.90 to 4.67), and simulated patient perceived empathy (mean difference 3.05; 95% CI 1.90 to 4.21). The associations of READ with knowledge, attitudes, and communication skills but not with simulated patient perceived empathy were partly mediated through student reported empathy and intergroup anxiety. CONCLUSION: This is the first study to identify mediating effects of reduced intergroup anxiety and increased empathy in an evaluation of anti-stigma training that includes behavioural measures in the form of communication skills and perceived empathy. It shows the importance of both mediators for all of knowledge, skills, and attitudes, and hence of targeting both in future interventions.

Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review.

BACKGROUND: We previously developed a Quality Improvement (QI) Return-on-Investment (ROI) conceptual framework for large-scale healthcare QI programmes. We defined ROI as any monetary or non-monetary value or benefit derived from QI. We called the framework the QI-ROI conceptual framework. The current study describes the different categories of benefits covered by this framework and explores the relationships between these benefits. METHODS: We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar, organisational journals, and citations, using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value) combined with healthcare and QI. Our analysis was informed by Complexity Theory in view of the complexity of large QI programmes. We used Framework analysis to analyse the data using a preliminary ROI conceptual framework that was based on organisational obligations towards its stakeholders. Included articles discussed at least three organisational benefits towards these obligations, with at least one financial or patient benefit. We synthesized the different QI benefits discussed. RESULTS: We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. Included articles were QI economic, effectiveness, process, and impact evaluations as well as conceptual literature. Based on these literatures, we reviewed and updated our QI-ROI conceptual framework from our first study. Our QI-ROI conceptual framework consists of four categories: 1) organisational performance, 2) organisational development, 3) external outcomes, and 4) unintended outcomes (positive and negative). We found that QI benefits are interlinked, and that ROI in large-scale QI is not merely an end-outcome; there are earlier benefits that matter to organisations that contribute to overall ROI. Organisations also found positive aspects of negative unintended consequences, such as learning from failed QI. DISCUSSION AND CONCLUSION: Our analysis indicated that the QI-ROI conceptual framework is made-up of multi-faceted and interconnected benefits from large-scale QI programmes. One or more of these may be desirable depending on each organisation's goals and objectives, as well as stage of development. As such, it is possible for organisations to deduce incremental benefits or returns-on-investments throughout a programme lifecycle that are relevant and legitimate.

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review.

BACKGROUND: Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes. METHODS: We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views. RESULTS: We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost-benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary. CONCLUSION: Our analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs. TRIAL REGISTRATION: Review registration: PROSPERO; CRD42021236948.

Perceived Acceptability and Experiences of a Digital Psychoeducation and Peer Support Intervention (COPe-support): Interview Study With Carers Supporting Individuals With Psychosis.

BACKGROUND: Web-based mental health interventions offer a novel, accessible, and self-paced approach to care delivery to family carers (ie, relatives and close friends who support a loved one with psychosis). We coproduced COPe-support (Carers fOr People with Psychosis e-support), a psychoeducational intervention delivered via an enriched web-based learning environment with network support from professionals and peers. In addition to the rigorous investigation of the effectiveness of COPe-support on the well-being of carers and mental health outcomes, it is imperative to understand the experiences of using the web-based intervention by carers and its associated web-based implementation and facilitation strategies. OBJECTIVE: This study aims to explore the experiences of carers and perceived acceptability of COPe-support and its different components, how carers found engagement with COPe-support affected their own well-being and caregiving, and the ideas of carers for improving COPe-support and its delivery to inform any future wider implementation. METHODS: We conducted a qualitative study, individually interviewing 35 carers, following their use of COPe-support for 8 months through a web-based, randomized controlled trial across England. A semistructured guide with open-ended questions was used to explore the experiences of carers and perceived acceptability of the intervention and their ideas to improve the provision. All interviews were conducted remotely through mobile phones or internet communication media, audio recorded and transcribed verbatim. We used a thematic analysis framework to analyze the data. RESULTS: Three key themes were identified: remote, flexible, and personalized support; impacts on well-being and outlook on caregiving; and future implementation and integration with existing services. Overall, carers found COPe-support a flexible source of knowledge and support from professionals and peers that they could personalize to suit their own needs and convenience. Participants described gaining self-confidence, hope, and a sense of connectivity with others in a similar situation, which helped ameliorate isolation and perceived stigma. Most importantly, COPe-support promoted self-care among the carers themselves. Participants' experiences, use, and activity on COPe-support varied greatly and differed among carers of various ages and levels of computer literacy. CONCLUSIONS: Nearly all participants had a positive experience with COPe-support and supported its wider implementation as a beneficial adjunctive support resource for carers in the future. Any future scale-up of such an intervention needs to consider feedback from carers and suggestions for further improvement. These included having more graphics and audiovisual content materials, improving the navigation, and building in more interactional and customization options to suit various user styles, such as emoji reactions, live web-based chat, opting in and out of updates, and choosing the frequency of reminders. To ensure successful implementation, we should also consider factors pertinent to reaching more carers and integrating the web-based resources with other conventional services. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 89563420; https://www.isrctn.com/ISRCTN89563420. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-020-02528-w.

Development of decision aid on health help-seeking for medical students.

BACKGROUND: Rates of mental health problems are increasing among medical students, who have added pressures compared with non-medical students. Medical student populations exhibit low rates of help-seeking and often struggle with disclosing health conditions due to the barriers experienced and concerns over negative repercussions. AIMS: This study aimed to create and test the feasibility and potential efficacy of an online decision aid (DA) tool that provides medical students with resources for disclosing and help-seeking for their health concerns. METHODS: The research used mixed methods, comprising two rounds of testing, the first used the Think-Aloud method to identify modifications needed, and both of which measured feasibility and assessed decision making outcomes pre and post use of the DA utilizing O'Connor's Decisional Conflict Scale (DCS) (2010) and Stage of Decision Making (SDM) (2003) measures. RESULTS: Results showed good feasibility of the DA. The mean DCS total score decreased from 32 to 16.75, (Wilcoxon signed-rank tests Z = -3.06, P < 0.05). There was no significant change in the SDM. CONCLUSIONS: The results suggest that the DA may reduce decisional conflict, improving their certainty and confidence in decision making, but had no immediate impact on their SDM, consistent with some other DAs. Further longitudinal research would be beneficial.