The potential of digital behavioural tests as a diagnostic aid for psychosis.

Timely interventions have a proven benefit for people experiencing psychotic illness. One bottleneck to accessing timely interventions is the referral process to the specialist team for early psychosis (STEP). Many general practitioners lack awareness or confidence in recognising psychotic symptoms or state. Additionally, referrals for people without apparent psychotic symptoms, although beneficial at a population level, lead to excessive workload for STEPs. There is a clear unmet need for accurate stratification of STEPs users and healthy cohorts. Here we propose a new approach to addressing this need via the application of digital behavioural tests. To demonstrate that digital behavioural tests can be used to discriminate between the STEPs users (SU; n = 32) and controls (n = 32, age and sex matched), we compared performance of five different classifiers applied to objective, quantitative and interpretable features derived from the 'mirror game' (MG) and trail making task (TMT). The MG is a movement coordination task shown to be a potential socio-motor biomarker of schizophrenia, while TMT is a neuropsychiatric test of cognitive function. All classifiers had AUC in the range of 0.84-0.92. The best of the five classifiers (linear discriminant classifier) achieved an outstanding performance, AUC = 0.92 (95%CI 0.75-1), Sensitivity = 0.75 (95%CI 0.5-1), Specificity = 1 (95%CI 0.75-1), evaluated on 25% hold-out and 1000 folds. Performance of all analysed classifiers is underpinned by the large effect sizes of the differences between the cohorts in terms of the features used for classification what ensures generalisability of the results. We also found that MG and TMT are unsuitable in isolation to successfully differentiate between SU with and without at-risk-mental-state or first episode psychosis with sufficient level of performance. Our findings show that standardised batteries of digital behavioural tests could benefit both clinical and research practice. Including digital behavioural tests into healthcare practice could allow precise phenotyping and stratification of the highly heterogenous population of people referred to STEPs resulting in quicker and more personalised diagnosis. Moreover, the high specificity of digital behavioural tests could facilitate the identification of more homogeneous clinical high-risk populations, benefiting research on prognostic instruments for psychosis. In summary, our study demonstrates that cheap off-the-shelf equipment (laptop computer and a leap motion sensor) can be used to record clinically relevant behavioural data that could be utilised in digital mental health applications.

Dementia services for people from Black, Asian and Minority Ethnic and White-British communities: Does a primary care based model contribute to equality in service provision?

This study set out to investigate whether there were disparities in service provision for people from Black, Asian and Minority Ethnic (BAME) communities compared to White British (WB) communities within a primary care led dementia service in the UK. Data were extracted from 30 cases from three BAME (African-Caribbean, South Asian and Chinese) communities who had been referred to a dementia service between April 2016 and December 2017. We then extracted data from 30 WB cases matched for gender, age (within 5 years) and General Practitioner surgery. We compared service provision for both samples around assessment, diagnosis and post-diagnostic support. The primary source of information in the BAME sample was less likely to be recorded as being the main carer and more likely to be an adult child. Cases from both samples were equally likely to have a CT scan. People from BAME communities were less likely to receive a cognitive assessment, and when they did they scored at a lower level. There was no difference between samples for the diagnoses that cases received, but BAME cases were more likely to be assessed as being low rather than medium or high risk. While cases from both samples were equally likely to receive medication, BAME cases were more likely to be seen by a psychiatrist. Significantly more people from the WB sample were recorded as using or being offered more than one form of community support. This study of a primary care-based dementia service suggests that while many areas of service provision showed no evidence of inequality, important differences remain including the time at which people present for assessment and the range of post-diagnostic services which are discussed. Further research is required to establish the likely causes of these disparities.

In a mental-health care setting, can nature conservation and health priorities align?

There is growing evidence that activities in nature could meet both health and nature conservation goals. Consequently, there is growing interest in collaborations between health and nature conservation organizations. However, interdisciplinary teamwork and collaborations risk failing through lack of common understanding and awareness of desired outcomes. For this project a multidisciplinary team was established and used a case study collaboration between a major conservation organization and health organization to examine perceptions of nature and assess the nature interventions desired by people in both sectors. We found a broad overlap in understanding of nature. However, there was a tendency for conservation outcomes to be overlooked, highlighting a potential risk of disengagement from the conservation partner. We recommend that health-conservation collaborations increase early communication and more strongly promote the interventions that provide tangible, physical benefits to nature.

Building an online community to promote communication and collaborative learning between health professionals and young people who self-harm: an exploratory study.

BACKGROUND: Online communities are known to break down barriers between supposed experts and non-experts and to promote collaborative learning and 'radical trust' among members. Young people who self-harm report difficulties in communicating with health professionals, and vice versa. AIM: We sought to bring these two groups together online to see how well they could communicate with each other about self-harm and its management, and whether they could agree on what constituted safe and relevant advice. METHODS: We allocated 77 young people aged 16-25 with experience of self-harm and 18 recently/nearly qualified professionals in relevant health-care disciplines to three separate Internet discussion forums. The forums contained different proportions of professionals to young people (none; 25%; 50% respectively) to allow us to observe the effect of the professionals on online interaction. RESULTS: The young people were keen to share their lived experience of self-harm and its management with health professionals. They engaged in lively discussion and supported one another during emotional crises. Despite registering to take part, health professionals did not actively participate in the forums. Reported barriers included lack of confidence and concerns relating to workload, private-professional boundaries, role clarity, duty of care and accountability. In their absence, the young people built a vibrant lay community, supported by site moderators. CONCLUSIONS: Health professionals may not yet be ready to engage with young people who self-harm and to exchange knowledge and experience in an anonymous online setting. Further work is needed to understand and overcome their insecurities.

Collaborative learning about e-health for mental health professionals and service users in a structured anonymous online short course: pilot study.

BACKGROUND: Professionals are interested in using e-health but implementation of new methods is slow. Barriers to implementation include the need for training and limited awareness or experience. Research may not always convince mental health professionals (MHPs). Adding the 'voice' of mental health service users (MHSUs) in collaborative learning may help. Involving MHSUs in face-face education can be difficult. We had previously been unable to engage MHPs in online discussion with MHSUs. Here we assessed the feasibility of short online courses involving MHSUs and MHPs. METHODS: We ran three e-health courses, comprising live interactive webcast, week's access to a discussion forum, and final live interactive webcast. We recruited MHPs via posters, newsletters, and telephone from a local NHS trust, and online via mailing lists and personal contacts from NHS trusts and higher education. We recruited MHSUs via a previous project and an independent user involvement service. Participants were presented with research evidence about e-health and asked to discuss topics using professional and lived experience. Feasibility was assessed through recruitment and attrition, participation, and researcher workloads. Outcomes of self-esteem and general self-efficacy (MHSUs), and Internet self-efficacy and confidence (MHPs) were piloted. RESULTS: Online recruiting was effective. We lost 15/41 from registration to follow-up but only 5/31 that participated in the course failed to complete follow-up. Nineteen MHPs and 12 MHSUs took part and engaged with each other in online discussion. Feedback was positive; three-quarters of MHPs indicated future plans to use the Internet for practice, and 80% of MHSUs felt the course should be continued. Running three courses for 31 participants took between 200 to 250 hours. Before and after outcome measures were completed by 26/31 that participated. MHP Internet self-efficacy and general Internet confidence, MHSU self-esteem and general self-efficacy, all seemed reliable and seemed to show some increase. CONCLUSIONS: Collaborative learning between MHSUs and MHPs in a structured online anonymous environment over a one-week course is feasible, may be more practical and less costly than face-face methods, and is worthy of further study.

Supportive interchanges and face-work as 'protective talk' in an online self-harm support forum.

Within a context of concern about inappropriate advice-giving online, we examined how young people who self-harm behave online, and how professionals might engage with them. We use Discourse Analysis to focus on participant interactions (posts)from a forum's crisis/support rooms, and highlight the prevalence of disclaimers, hedges, questions and tags in the young people's online interactions. We use the concept of face-work as a framework to help understand interactions in the forum SharpTalk. The findings demonstrate the use of a range of mitigation devices, and suggest that the young people orientate to a 'protective' line in their supportive interactions. These findings echo Goffman's (1967) 'supportive interchanges' in that the young people's online interactions may help to preserve face, in an emotionally complex setting, whose vulnerable members also need 'protective'and sensitive support. Taking this 'line' may enable members to create a more open and trusting context for support, and to remain in a forum which they find both helpful and challenging. In light of concerns about online support, the findings provide a new perspective on online peer-support for young people who self-harm.

Ethical practice in internet research involving vulnerable people: lessons from a self-harm discussion forum study (SharpTalk).

The internet is widely used for health information and support, often by vulnerable people. Internet-based research raises both familiar and new ethical problems for researchers and ethics committees. While guidelines for internet-based research are available, it is unclear to what extent ethics committees use these. Experience of gaining research ethics approval for a UK study (SharpTalk), involving internet-based discussion groups with young people who self-harm and health professionals is described. During ethical review, unsurprisingly, concerns were raised about the vulnerability of potential participants. These were dominated by the issue of anonymity, which also affected participant safety and consent. These ethical problems are discussed, and our solutions, which included: participant usernames specific to the study, a closed website, private messaging facilities, a direct contact email to researchers, information about forum rules displayed on the website, a 'report' button for participants, links to online support, and a discussion room for forum moderators. This experience with SharpTalk suggests that an approach to ethics, which recognises the relational aspects of research with vulnerable people, is particularly useful for internet-based health research. The solutions presented here can act as guidance for researchers developing proposals and for ethics committees reviewing them.

Membership and boundary maintenance on an online self-harm forum.

In this article we explore how young adults became members and sustained membership in an online self-harm support forum, SharpTalk. We take a discursive approach to consider resources young people used to establish themselves, how others responded to their attempts, and how membership categories were developed and applied. Participants displayed expectations about appropriate ways of discussing self-harm, and about responses and advice. New posters made reference to other self-harm sites, provided biomedicalized narratives of their "story," and asked for help in particular ways. Participants were active in shaping interactions on the forum, requesting input from site moderators, and challenging each other both on perceived infringements of posting content, and on style of posting pertinent to membership. On the SharpTalk site, perceived deviance in posting behavior, and also the giving of health care advice, were most commonly addressed by other young people who self-harmed, rather than by the site moderators. We consider implications for creating sites that enable young people who self-harm to become members and sustain membership, and therefore access support.

Using metrics to describe the participative stances of members within discussion forums.

BACKGROUND: Researchers using forums and online focus groups need to ensure they are safe and need tools to make best use of the data. We explored the use of metrics that would allow better forum management and more effective analysis of participant contributions. OBJECTIVE: To report retrospectively calculated metrics from self-harm discussion forums and to assess whether metrics add to other methods such as discourse analysis. We asked (1) which metrics are most useful to compare and manage forums, and (2) how metrics can be used to identify the participative stances of members to help manage discussion forums. METHODS: We studied the use of metrics in discussion forums on self-harm. SharpTalk comprised five discussion forums, all using the same software but with different forum compositions. SharpTalk forums were similar to most moderated forums but combined support and general social chat with online focus groups discussing issues on self-harm. Routinely recorded time-stamp data were used to derive metrics of episodes, time online, pages read, and postings. We compared metrics from the forums with views from discussion threads and from moderators. We identified patterns of participants' online behavior by plotting scattergrams and identifying outliers and clusters within different metrics. RESULTS: In comparing forums, important metrics seem to be number of participants, number of active participants, total time of all participants logged on in each 24 hours, and total number of postings by all participants in 24 hours. In examining participative stances, the important metrics were individuals' time logged per 24 hours, number of episodes, mean length of episodes, number of postings per 24 hours, and location within the forum of those postings. Metric scattergrams identified several participative stances: (1) the "caretaker," who was "always around," logged on for a much greater time than most other participants, posting but mainly in response to others and rarely initiating threads, (2) the "butterfly," who "flitted in and out," had a large number of short episodes, (3) two "discussants," who initiated many more discussion threads than anybody else and posted proportionately less in the support room, (4) "here for you," who posted frequently in the support room in response to other participants' threads, and (5) seven "people in distress," who posted many comments in the support room in comparison with their total postings and tended to post on their own threads. CONCLUSIONS: Real-time metrics may be useful: (1) by offering additional ways of comparing different discussion forums helping with their management, and (2) by identifying participative stances of individuals so allowing better moderation and support of forums, and more effective use of the data collected. For this to happen, researchers need to publish metrics for their discussion forums and software developers need to offer more real-time metrics facilities.

Involving service users in intervention design: a participatory approach to developing a text-messaging intervention to reduce repetition of self-harm.

OBJECTIVE To engage a group of people with relevant lived experience in the development of a text-messaging intervention to reduce repetition of self-harm. BACKGROUND Contact-based interventions, such as follow-up letters, postcards and telephone calls, have shown potential to reduce repetition of self-harm in those who present at Accident and Emergency departments. Text messaging offers a low-cost alternative that has not been tested. We set out to develop a text-based intervention. The process of intervention development is rarely reported and little is known about the impact of service user involvement on intervention design. METHOD We held a series of six participatory workshops and invited service users and clinicians to help us work out how to get the right message to the right person at the right time, and to simulate and test prototypes of an intervention. RESULTS Service users rejected both the idea of a generic, 'one size fits all' approach and that of 'audience segmentation', maintaining that text messages could be safe and effective only if individualized. This led us to abandon our original thinking and develop a way of supporting individuals to author their own self-efficacy messages and store them in a personal message bank for withdrawal at times of crisis. CONCLUSIONS This paper highlights both the challenge and the impact of involving consumers at the development stage. Working with those with lived experience requires openness, flexibility and a readiness to abandon or radically revise initial plans, and may have unexpected consequences for intervention design.

Suicides in public places: findings from one English county.

Little is known about where suicides take place. We collected data from coroners' files on all suicides and undetermined deaths in one large English county from 2000 to 2004. The data show that >30% of suicides occurred in public places. A quarter of these involved jumping from a height and nearly a quarter involved car exhaust poisoning. Several sites were associated with multiple methods of suicide. Identifying and managing high-risk locations should be an important part of an overall suicide prevention strategy and is best tackled at local level.