Does a comprehensive service user-led education programme effect more positive attitudes towards recovery and less stigmatising attitudes towards people with lived experience of mental distress in medical students? A comparative cohort study.

OBJECTIVE: This study sought to investigate the impact of a service user-led anti-stigma and discrimination education programme, encompassing numerous interventions focused on facilitating multiple forms of social contact, the promotion of recovery, and respect for human rights, on medical student attitudes. METHOD: A comparison cohort study was used to compare the attitudes of two cohorts of medical students who received this programme as part of their fifth (the fifth-year cohort) or sixth (the sixth-year cohort) year psychological medical education attachment (programme cohorts) with two cohorts of equivalent students who received a standard psychological medical attachment (control cohorts). Attitudes to recovery (using the Recovery Attitudes Questionnaire) and stigma (using the Opening Minds Scale for Healthcare Providers) were measured at the beginning and end of the attachments for each year and compared both within and between the cohorts using Wilcoxon signed-rank or Wilcoxon rank-sum tests. RESULTS: With sample sizes ranging from 46 to 70 across all cohorts, after their psychological medicine attachment both the programme and control cohorts showed more positive attitudes towards recovery and less stigmatising attitudes towards people with lived experience of mental distress. Significant differences between the programme cohorts and the control cohorts were found for recovery attitudes (median difference of 2, p < 0.05 in both fifth and sixth year), with particularly large differences being found for the 'recovery is possible and needs faith' subdomain of the Recovery Attitudes Questionnaire. There were no significant between cohort differences in terms of stigmatising attitudes as measured by the Opening Minds Scale for Healthcare Providers. CONCLUSION: The introduction of a comprehensive service user-led anti-stigma and education programme resulted in significant improvements in recovery attitudes compared to a control cohort. However, it was not found to be similarly superior in facilitating less stigmatising attitudes. Various possible reasons for this are discussed.

A comparative analysis of two alternative programmes to counter stigma and discrimination associated with mental illness delivered to medical students.

OBJECTIVE: To assess and compare attitudes of medical students in response to two service-user-led anti-stigma and discrimination education programmes. METHOD: Two programmes, consistent with the key elements of effective contact-based anti-stigma and discrimination education programmes for healthcare providers, were delivered to medical students in their penultimate and final year: a more intensive version of the programme in 2015/2016 and a briefer programme in 2016/2017. Attitudes were assessed using the Recovery Attitudes Questionnaire (RAQ) and the Opening Minds Stigma Scale for Health Care Providers (OMS-HC-20) at the beginning and end of their final year. RESULTS: There were no significant differences between the years in initial scores on either scale. Both cohorts showed statistically significant reductions in scores on both scales after completion of the programme, indicating overall improvements in students' attitudes with reductions in stigma, and more positive attitudes towards recovery of those in mental distress. The more intensive programme led to significantly greater improvement in reductions in stigma than the less intensive programme. CONCLUSION: Findings support the need for contact-based anti-stigma and discrimination education programmes for medical students that are both intensive and repeated over time.

Key Ingredients-Target Groups, Methods and Messages, and Evaluation-of Local-Level, Public Interventions to Counter Stigma and Discrimination: A Lived Experience Informed Selective Narrative Literature Review.

A proliferation of recent literature provides substantial direction as to the key ingredients-target groups, messages and methods, and evaluation-of local-level, public interventions to counter stigma and discrimination. This paper provides a selective narrative review of that literature from the perspective or standpoint of anti-stigma experts with lived experience of mental distress, the key findings of which have been synthesised and presented in diagrammatic overviews (infographics). These are intended to guide providers in planning, delivering and evaluating lived experience-directed local-level, public interventions to counter stigma and discrimination in accord with current best practice.

New Zealand's mental health legislation needs reform to avoid discrimination.

New Zealand's Mental Health (Compulsory Assessment and Treatment) Act (the Act) is now over 20 years old. As has occurred historically our conceptualisation of humane treatment of people with mental illness has altered significantly over the period in which the Act has been in force. The emergence of the philosophy of recovery, and its subsequent policy endorsement, has seen a significant shift in mental health service delivery towards a greater emphasis on autonomy. Human rights developments such as New Zealand's ratification of the 2006 United Nations Convention on the Rights of Persons with Disabilities have resulted in compulsory treatment, where it is justified in whole or part by a person's mental illness, now being considered antithetical to best practice, and discriminatory. However the number of people subject to the Act is increasing, especially in community settings, and it is questionable how effective the mechanisms for challenging compulsion are in practice. Moreover, monitoring of the situation at the systemic level lacks critical analysis. Complacency, including no indication that review and reform of this now antiquated legislation is nigh, continues a pattern of old where the situation of people with experience of mental illness is largely ignored and neglected.

Modified criteria for the systemic inflammatory response syndrome improves their utility following cardiac surgery.

BACKGROUND: Debate remains regarding whether the systemic inflammatory response syndrome (SIRS) identifies patients with clinically important inflammation. Defining criteria may be disproportionately sensitive and lack specificity. We investigated the incidence and evolution of SIRS in a homogenous population (following cardiac surgery) over 7 days to establish the relationship between SIRS and outcome, modeling alternative permutations of the criteria to increase their discriminatory power for mortality, length of stay, and organ dysfunction. METHODS: We conducted a retrospective analysis of prospectively collected data from a cardiothoracic ICU. Consecutive patients requiring ICU admission for the first time after cardiac surgery (N = 2,764) admitted over a 41-month period were studied. RESULTS: Concurrently, 96.2% of patients met the standard two criterion definition for SIRS within 24 h of ICU admission. Their mortality was 2.78%. By contrast, three or four criteria were more discriminatory of patients with higher mortality (4.21% and 10.2%, respectively). A test dataset suggested that meeting two criteria for at least 6 consecutive h may be the best model. This had a positive and negative predictive value of 7% and 99.5%, respectively, in a validation dataset. It performed well at predicting organ dysfunction and prolonged ICU admission. CONCLUSIONS: The concept of SIRS remains valid following cardiac surgery. With suitable modification, its specificity can be improved significantly. We propose that meeting two or more defining criteria for 6 h could be used to define better populations with more difficult clinical courses following cardiac surgery. This group may merit a different clinical approach.

Discovering stigma through recovery teaching.

OBJECTIVE: From the perspective of the tutor, course coordinators and a clinical supervisor, we describe and reflect on our observations of innovative service-user led tutorials on recovery that were delivered to final year medical students as part of their psychiatric module. CONCLUSIONS: Much to our surprise, and in contrast to observations elsewhere during the module, students openly expressed blatant stigmatising attitudes in the tutorials on recovery, particularly after spending time with inpatient services. More specifically, they were pessimistic about the possibility of recovery and they struggled to accept the service user status of the recovery tutor. This prompted us to reflect on what and how we teach psychiatry.

Core dimensions of recovery: a psychometric analysis.

Core recovery dimensions lie between the large general factor of recovery and its underlying components. Identifying these could enhance recovery frameworks, practice and research. In contrast to existing conceptually based taxonomies, we sought to empirically identify the core dimensions of recovery through further psychometric analysis of a robust eleven factor (sub-scale) consumer recovery outcome measure, My Voice, My Life. We subjected the sub-scale scores of 504 consumers to further principal components analyses, beginning with a single unrotated factor and progressing through two to nine factors with varimax rotation. We found the five-factor solution to provide an orderly intermediate configuration with the eleven recovery factors having either aligned and/or disengaged through the process to result in the following core dimensions: (1) Belonging and relating (encompassing the individual factors of spirituality, culture, and relationships); (2) Being and doing (encompassing the individual factors of physical health, day-to-day life, and quality of life); (3) Thinking and feeling (encompassing the individual factors of recovery, mental health, and hope and empowerment); (4) Resources (which maintained its independence); and (5) Satisfaction with Services (which also maintained its independence). We compare this empirical configuration with conceptually based taxonomies.

Recovery of evidence-based practice.

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence-based practice (EBP) is judged. From a consumer-recovery perspective, this paper re-examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery-focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.

Development of a self-assessed consumer recovery outcome measure: my voice, my life.

We report the development of a self-assessed consumer recovery outcome measure by way of a consumer led and focused iterative process, informed by exploratory and confirmatory factor analysis. The process began with a deliberately over-inclusive preliminary measure of 127 items, based on 12 presumptive domains derived from the recovery literature and consumer consultation, being piloted with over 500 mental health consumers. The full 504 participant data set was randomly split into two discrete sets of 300 and 204 to provide one for the initial exploratory factor analysis and another (of independence) for the subsequent confirmatory factor analysis and reliability estimation. Analyses identified and confirmed (using the separate data sets) a robust factor structure, with 11 distinct and relatively independent factors (relationships; day-to-day life; culture; physical health; quality of life; mental health; recovery; hope and empowerment; spirituality; resources; and satisfaction with services) underlying one substantial principal construct (that we refer to as consumer recovery). The measure was refined to 65 items, between three and ten items for each of the 11 domains, the reliabilities for which are uniformly high.

Investigation of endothelial function by pulse contour analysis: a protocol for drug administration and timing of pulse contour assessment.

AIMS: Pulse contour analysis (PCA) obtained by finger photoplethysmography produces a digital volume pulse (DVP) including an inflection point in its down-slope. The reflection index (RI: ratio of the inflection point height over the maximal DVP) is responsive to vasodilatation. We aimed to optimize the drug dose and time interval for assessing endothelial function using PCA in healthy volunteers and patients with severe coronary artery disease. METHODS: Time and dose to RI response relationships were constructed in 16 volunteers and nine patients to inhaled salbutamol (100-400 microg) or sublingual nitroglycerin (NTG; 25-400 microg). RESULTS: For the volunteers, the time to maximum RI response to inhaled salbutamol and sublingual NTG was 10.73 +/- 0.41 and 3.66 +/- 0.21 min, respectively. A plateau in the RI response to salbutamol occurred between 5 and 15 min after inhalation and results were averaged over this period. A dose-dependent response was observed to inhaled salbutamol and sublingual NTG (P= 0.05 and P < 0.001 by repeated-measures anova, respectively) in healthy volunteers. By contrast, in patients with severe coronary artery disease inhaled salbutamol (100-400 microg) did not cause a significant change in RI. CONCLUSIONS: In healthy volunteers the RI response to inhaled salbutamol (100-200 microg) averaged over 5-15 min after administration may be used to investigate endothelial function by PCA. The response to sublingual NTG (50 microg) should be determined at 4 min. This technique may not be suitable for the assessment of endothelial function in subjects with extensive coronary artery disease owing to the small responses observed and potential confounding effect of vasoactive medication.