Young People Talk About Digital Support for Mental Health: An Online Survey of 15-30-Year Olds in New Zealand.

BACKGROUND: Mental distress is on the rise for young people, and there are high levels of unmet need for support. Increasingly, young people are engaging with online mechanisms of support to avoid cost and wait times; however, online support does have its limitations. We surveyed young people, 15-30 years of age, in Aotearoa New Zealand to explore their views of digital support for mental health. The aim of this study was to find out from young people what they thought about various types of online support and perceived benefits and drawbacks. METHODS: A cross-sectional online survey promoted through social media advertising was used. Participants included anyone aged 15-30 years living in Aotearoa New Zealand. The survey ran for 10 weeks between February and May 2022. It included demographic questions and asked about (i) use of digital support for mental health; (ii) what digital support is best used for; (iii) best ways of publicising mental health supports to young people; and (iv) where they would choose to get information about mental health support. Questions were a mix of forced choice and free text. Participants could opt to take part in a follow-up interview. RESULTS: Surveys were completed by 1471 participants; two respondents participated in an interview. A total of 641 participants had used digital support before (44%). The most used forms of digital support were websites (n = 324) and watching videos (n = 260), although these were not necessarily rated as the most helpful. Alternatives that people most wanted to try were podcasts and phone or video consultations with a counsellor or therapist. Drawbacks of digital support included privacy concerns, technical issues, lack of quality and motivation requirements. Benefits included ease of access, anonymity and a non-threatening starting point. CONCLUSIONS: Digital support has a place in mental health care, but strong sentiment was expressed in favour of real-life support. It may also be worth investing in more innovative types of digital support such as online performing arts and podcasts. PATIENT OR PUBLIC CONTRIBUTION: A group of young people were recruited as co-researchers, had input into survey design, data analysis and interpretation and are co-authors (list of co-authors). Survey respondents also included young people with lived experience who are members of the general public.

Evaluating Success and Challenges of a Primary Care Youth Mental Health Programme Using Complexity, Implementation Science, and Appreciative Inquiry.

Background Using an innovative framework of complexity and implementation science, with underpinning core values of appreciative inquiry (CIS-A), this paper describes the evaluation of a pilot service in New Zealand aiming to deliver integrated psychological therapy services within primary care, to young people (aged 18-24) experiencing mild to moderate mental distress. Method Using mixed quantitative and qualitative methods and multiple data sources, there was a strong focus on local innovation and co-design with service users, young people and multiple care providers. Data is drawn from service users, stakeholders and providers of the service in three areas of the lower North Island of New Zealand.  Results The Piki pilot provided a significant and innovative enhancement of mental health care to this population. The service supported 5307 individuals with a range of therapy options, with the majority having between one and three therapy sessions. From 730 service users who completed a survey, 591 (81%) were 'very satisfied' with the service provided. The CIS-A framework was used successfully to provide rapid feedback and encourage adaptation to evolving issues. These included unexpected workload pressures, changes to therapy delivery, the integration of co-design and prioritising the needs of vulnerable groups. There was a successful incorporation of youth/service user input to co-design the programme, introduction of a peer-to-peer support service, and integration of a digital resource platform. The framework was also used to address challenges encountered and to support necessary adaptations in response to the COVID-19 pandemic.  Conclusions We describe the use of an embedded evaluation to support and inform the implementation of a novel and innovative youth mental health programme. Complexity and implementation science, underpinned by the core values of appreciative inquiry (CIS-A), were successfully utilised providing potential learning that can be applied locally, nationally and internationally. This study has a focus on youth mental health but the principles and utility of applying a complexity and implementation science approach have application in many different health care settings. The use of a framework such as CIS-A can support complex innovation and implementation and can be used to enable rapid course correction and turn 'hindsight to foresight'.

Therapist Voices on a Youth Mental Health Pilot: Responsiveness to Diversity and Therapy Modality.

This article explores therapists' views on a large youth mental health pilot project (for 18-25-year-olds), which included an individual cognitive behavior therapy (CBT)-informed individual therapy component. Therapists' views on cultural responsiveness, therapy (delivery, modality and duration) and working with LGBTQIA+ youth were explored using two surveys, individual interviews and focus groups at various stages of the life of the pilot. Some therapists saw the CBT approach as imposed on them, preferring familiar therapy modalities. Many therapists were positive toward CBT for its client-centered approach and reported using CBT-informed approaches with many of their clients to good effect. Some therapists felt pressured by their workplace to see clients for fewer sessions than they needed. Therapists wanted to see a more culturally diverse workforce, to increase their cultural competence through training and to have more easily available cultural supervision. There was some acknowledgement of the importance of training therapists to work competently with LGBTQIA+ young people. Involving therapists in co-design of services from the outset will likely benefit future service development.

Single-session Mentalization-based Treatment Group for Law Enforcement Officers.

Law enforcement violence has emerged as a leading public health concern, and law enforcement officers are themselves at greater risk for a range of psychiatric disorders. Drawing on the significant empirical support for mentalization-based treatment (MBT), this paper explores the use of MBT as a transdiagnostic psychotherapy for law enforcement professionals. By helping patients to mentalize-that is, to "read," access, and reflect on mental states in oneself and other people-MBT could be useful as a dual-focus treatment, able to simultaneously impact psychiatric illness among law enforcement officers while also indirectly impacting the problem of law enforcement violence in the broader society. The core psychotherapeutic principles of MBT are reviewed, along with common vulnerabilities in mentalizing likely to arise for law enforcement professionals in the context of high emotional and interpersonal intensity. The authors outline a novel application of MBT which has implications for psychiatric treatment as well as police training: the single-session psychoeducation and psychotherapy group, where law enforcement officers practice both self-reflection and empathy in situations of relational conflict. Utilizing group process from a residential treatment program for first responders with mental health and substance use disorders, a case example is offered to illustrate this intervention.

Cluster randomised controlled trial of a guided self-help mental health intervention in primary care.

OBJECTIVES: To ascertain whether an ultrabrief intervention (UBI) improves mental health outcomes for patients in general practice with mild-to-moderate mental health concerns. TRIAL DESIGN: Two-arm cluster randomised controlled trial. METHODS: Participants: general practitioners (GPs) were invited based on working in a participating general practice. Patients were eligible to participate if aged 18-65 years, scored ≤35 on the Kessler-10 (K10) and if meeting local mental health access criteria (based on age, low income or ethnic group). INTERVENTIONS: intervention arm GPs were trained on the UBI approach, with participating patients receiving three structured appointments over 5 weeks. GPs randomised to practice as usual (PAU) did not receive training, and delivered support following their existing practice approaches. OUTCOME MEASURES: primary outcome was patient-level K10 score at 6 months postrecruitment.Randomisation: GP practices were randomised to UBI training or PAU at the start of the study.Blinding: GPs were not blinded to group assignment. RESULTS: Numbers randomised: 62 GPs (recruiting 85 patients) were randomised to UBI, and 50 to PAU (recruiting 75 patients).Numbers analysed: 31 GPs recruited at least one patient in the UBI arm (70 patients analysed), and 21 GPs recruited at least one patient in the PAU arm (69 patients analysed). OUTCOME: K10 scores from an intention-to-treat analysis were similar in UBI and PAU arms, with a wide CI (mean adjusted K10 difference=1.68 points higher in UBI arm, 95% CI -1.18 to 4.55; p=0.255). Secondary outcomes were also similar in the two groups. CONCLUSIONS: the UBI intervention did not lead to better outcomes than practice as usual, although the study had lower than planned power due to poor recruitment. The study results can still contribute to the continuing debate about brief psychological therapy options for primary care and their development. TRIAL REGISTRATION NUMBER: ACTRN12613000041752; Pre-results.

A taboo topic? How General Practitioners talk about overweight and obesity in New Zealand.

INTRODUCTION Obesity is overtaking tobacco smoking in New Zealand as the leading potentially modifiable risk to health. International obesity guidelines recommend that health professionals opportunistically encourage weight management with their patients. However, research shows consistently low rates of weight management discussion, suggesting that health professionals may not be realising their full potential to address obesity. AIM To identify communication strategies used by General Practitioners (GPs) to open the topic of weight and weight management in routine consultations. METHODS A secondary analysis was conducted of 36 video-recorded consultations in general practices, selected for relevance from a database of 205 consultations. Content and interactional analysis was conducted in the context of the entire consultation. RESULTS The topic of weight was initiated more often by GPs than patients and was raised mostly once or twice in a consultation and occasionally as many as six times. GPs employed opportunistic strategies twice as often as they used structured strategies. DISCUSSION This study of naturally occurring consultations confirmed GPs do engage in opportunistic discussions about weight. However, such discussions are challenging and interactionally delicate. Highlighting the clinical relevance of weight appears to be effective. The high frequency of patient contact with GPs provides opportunity to reach and work with people at risk of chronic conditions associated with excess weight. Further research is required to identify suitable training and brief intervention tools for use in routine consultations that may be beneficial for both GPs and patients.

A Longitudinal Study of Interactions Between Health Professionals and People With Newly Diagnosed Diabetes.

PURPOSE: We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur. METHODS: All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis. RESULTS: Challenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ. CONCLUSIONS: Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.

'It depends on the consultation': revisiting use of family members as interpreters for general practice consultations - when and why?

Family members continue to be used as interpreters in medical consultations despite the well-known risks. This paper examines participant perceptions of this practice in three New Zealand clinics chosen for their frequent use of interpreters and their skill in using them. It is based on a detailed study of 17 video-recorded interpreted consultations and 48 post-consultation interviews with participants (5 doctors, 16 patients and 12 interpreters, including 6 family members). All participants expressed satisfaction with the communication. Analysis of the interviews explored what participants liked or valued about family member interpreters (FMIs). Key themes were the FMIs' personal relationship and knowledge, patient comfort, trust, cultural norms, time efficiency and continued help outside the consultation. General practitioners (GPs) expressed awareness of potential risks and how to manage them, in contrast to patients and FMIs. Although the use of professional interpreters needs to be strongly promoted, a well-informed decision to use a family member is appropriate in some situations. GPs need to be well trained in how to assess and manage the risks. Rather than striving for 'best practice' (i.e. universal use of professional interpreters), it is better to aim for 'good practice' where a considered judgement is made about each situation on an individual basis.

Patient resistance as a resource: candidate obstacles in diabetes consultations.

This study uses conversation analysis to explore 'candidate obstacles', a practice observed in sequences of patient resistance to lifestyle advice within health professional consultations. This article presents illustrative analyses of selected data excerpts drawn from audio-visual recordings of 116 tracked consultations between health professionals and 34 patients newly diagnosed with type 2 diabetes mellitus in New Zealand. The analysis shows that in consultations where health promotion activities are central, patient resistance can provide space for patients to identify obstacles to their compliance with lifestyle advice. Identifying candidate obstacles provides opportunities for health professionals to align advice with concerns of patients and potentially improve patient outcomes.

Non-physiological mechanisms influencing disulfiram treatment of alcohol use disorder: A grounded theory study.

BACKGROUND: The mechanism of action of disulfiram is not clear and recent systematic reviews have reached differing conclusions. The purpose of this research was to develop a conceptual model of the mechanisms that underpin the effective use of disulfiram in management of alcohol used disorder. METHODS: Grounded theory was used, based on anonymized transcripts of in-depth interviews with 14 individual clients who experienced taking disulfiram for alcohol use disorder within the context of a specialized clinic setting from New Zealand. RESULTS: The central concept was that of abstinence being a psychosocial construction, with the taking of disulfiram, being a physical manifestation of the decision not to drink. The main subthemes included the importance of participants believing in the potential for disulfiram producing a negative reaction, the increased autonomy achieved by disulfiram removing the need to ruminate on drinking decisions, and the importance of external structure, routine, and social contact with others to support ongoing engagement with disulfiram therapy. CONCLUSIONS: The physiological effects of disulfiram, in particular its adverse reaction when combined with alcohol, explains only part of its effect on problem drinking behaviour. The act of taking a disulfiram pill is also partly symbolic of making an absolute decision not to drink for a short period, allowing people with alcohol use disorder to explore other options for managing life without alcohol. Drug trials involving disulfiram need to treat it not simply as pharmaceutical but as part of a complex psychosocial intervention conducted within a supportive social context.

Certainty and uncertainty about end of life care nursing practices in New Zealand Intensive Care Units: a mixed methods study.

BACKGROUND: With end-of-life (EOL) central to the nursing role in intensive care, few studies have been undertaken to explore EOL care in the context of New Zealand (NZ) intensive care nursing. OBJECTIVE: To investigate NZ intensive care nurses' experiences of, and attitudes towards EOL care. DESIGN: Sequential mixed methods study using cross sectional survey with follow-on focus groups. METHODS: NZ intensive care nurses (N=465) across four large tertiary intensive care units (ICUs) were contacted to complete a 43-item web-based survey. A follow-on focus group was conducted in each of the sites to explore specific aspects of the survey findings. RESULTS: 203 fully completed surveys were returned (response rate 44%) from the four ICUs. Over half of nurses surveyed (55%, n=111) disagreed that withholding and withdrawing life support treatment were ethically the same. 78% (n=159) of nurses stated that withholding treatment was ethically more acceptable than withdrawing it. Whilst nurses generally supported reducing inspired oxygen to air for ventilated patients at EOL (71%, n=139) this was also an area that demonstrated one of the highest levels of uncertainty (21%, n=41). Just under a quarter of respondents were also uncertain about the use of continued nutritional support, continued passive limb exercises and use of deep sedation during EOL. The 18 nurses who participated in follow-on focus groups detailed the supportive, culturally sensitive, collaborative environment that EOL was conducted in. However diverse opinions and understandings were held on the use of passive limb and use of fluids at EOL. CONCLUSIONS: Whilst results from this NZ study broadly align with European studies, uncertainty about specific areas of EOL practices highlight that further guidance for nurses is required.

An instrument approach to airway management.

Aviation terminology and thought processes are commonly applied to medicine. We further propose the adaptation of instrument flight terminology to emergency airway management including the aviation approach plate visual aid and replacement of the term "failed airway" with "missed airway,"

General practitioner opinion of weight management interventions in New Zealand.

INTRODUCTION: Internationally, a number of studies have investigated general practitioner (GP) opinion of weight management interventions. To date there have been no similar studies carried out in New Zealand. This study aimed to explore GP opinion of weight management interventions in one region of New Zealand. Understanding GP opinion is important, as rates of obesity are increasing and GPs are front-line health care service providers. The data collected could be used to guide health service development in New Zealand, and to inform training and support of GPs in obesity management. METHODS: A qualitative study using inductive thematic analysis of a series of 12 semi-structured interviews with GPs in the Wellington region of New Zealand. FINDINGS: Five key themes were identified: 1) GP perceptions of what the GP can do; 2) the roots of the obesity problem; 3) why the GP doesn't succeed; 4) current primary care interventions; and 5) bariatric surgery. CONCLUSION: The GPs interviewed felt responsible for treatment of obesity in their patients. They expressed a sense of disempowerment regarding their ability to carry this out, identifying multiple barriers. These included: a society where overweight is seen as normal; complex situations in which weight management is rooted in personal issues; stigma associated with overweight and its management; lack of efficacious interventions; and low resource availability. Bariatric surgery was viewed cautiously in general, though some examples of positive results were reported, as well as a desire for increased access to this treatment option.

Nurse-patient communication in primary care diabetes management: an exploratory study.

BACKGROUND: Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management. METHODS: Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared. RESULTS: This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses' clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations. CONCLUSIONS: Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.

Challenges to alcohol and other drug discussions in the general practice consultation.

BACKGROUND: There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. AIM: To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. DESIGN: Analysis of video-recorded primary care consultations. SETTING: New Zealand General Practice. METHODS: Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. RESULTS: AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. CONCLUSIONS: Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.