Protecting and promoting editorial independence.

We argue that editorial independence, through robust practice of publication ethics and research integrity, promotes good science and prevents bad science. We elucidate the concept of research integrity, and then discuss the dimensions of editorial independence. Best practice guidelines exist, but compliance with these guidelines varies. Therefore, we make recommendations for protecting and strengthening editorial independence.

Virtual reality relaxation for people with mental health conditions: a systematic review.

PURPOSE: Vulnerability to stress is linked to poor mental health. Stress management interventions for people with mental health conditions are numerous but they are difficult to implement and have limited effectiveness in this population. Virtual reality (VR) relaxation is an innovative intervention that aims to reduce stress. This review aimed to synthesize evidence of VR relaxation for people with mental health conditions (PROSPERO 269405). METHODS: Embase, Medline, PsycInfo, and Web of Science were searched until 17th September 2021. The review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The Effective Public Health Practice Project (EPHPP) tool assessed methodological quality of studies. RESULTS: Searching identified 4550 studies. Eighteen studies (N = 848) were included in the review. Studies were published between 2008 and 2021. Eleven were conducted in Europe. Thirteen studies were controlled trials. Participants were mostly working-age adult outpatients experiencing anxiety or stress-related conditions. Other conditions included eating disorders, depression, bipolar disorder, and psychosis. Five studies tested inpatients. All studies used a range of nature-based virtual environments, such as forests, islands, mountains, lakes, waterfalls, and most commonly, beaches to promote relaxation. Studies provided evidence of the feasibility, acceptability, and short-term effectiveness of VR relaxation to increase relaxation and reduce stress. EPHPP ratings were 'strong' (N = 11), 'moderate' (N = 4), and 'weak' (N = 3). CONCLUSIONS: VR relaxation has potential as a low-intensity intervention to promote relaxation and reduce stress for adults with mental health conditions, especially anxiety and stress-related problems. Further research is warranted on this promising intervention.

Current appeal system for those detained in England and Wales under the Mental Health Act needs reform.

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their will. This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered.

It is ethical to diagnose a public figure one has not personally examined.

Should psychiatrists be able to speculate in the press or social media about their theories? John Gartner argues the risk to warn the public of concerns about public figures overrides the duty of confidentiality; whereas Alex Langford suggests this is beyond the ethical remit of psychiatric practice.Declaration of interestA.O'B is joint debates and analysis Editor of the British Journal of Psychiatry. J.G. is the founder of Duty To Warn, an association of mental health professionals who advocate the president's removal under the 25th Amendment on the grounds that he is psychologically unfit and dangerous.

Restraint in mental health settings: is it time to declare a position?

The emergence of a drive to reduce restrictive interventions has been accompanied particularly in the UK by a debate focussing on restraint positions. Any restraint intervention delivered poorly can potentially lead to serious negative outcomes. More research is required to reliably state the risk attached to a particular position in a particular clinical circumstance.Declaration of interestF.S. is a consultant psychiatrist in Psychiatric Intensive Care at the Maudsley Hospital, London. He is on the Executive Committee of the National Association of Psychiatric Intensive Care and Low Secure Units, and was a member of the National Institute for Health and Care Excellence Guideline Development Group for the Short-Term Management of Aggression and Violence (2015). J.P. is a senior lecturer at the Faculty of Health and Life Sciences, Coventry University. E.B. is a consultant and expert witness in violence reduction and the use of physical interventions, independent expert to the High Secure Hospitals Violence Reduction Manual Steering Group and a member of the College of Policing Guideline Committee Steering Group and Mental Health Restraint Expert Reference Group. B.P. is the clinical director for Crisis and Aggression Limitation and Management (CALM) Training and formerly a senior lecturer for the Faculty of Health, University of Stirling. He is a nurse and psychotherapist and presently chairs the European Network for Training in the Management of Aggression. A.O'B. is a consultant psychiatrist, the Director of Educational Programmes for the National Association of Psychiatric Intensive Care and Low Secure Units, and the Dean for Students at St George's University of London.

Public mental health crisis management and Section 136 of the Mental Health Act.

The interface between mental health services and the criminal justice system presents challenges both for professionals and patients. Both systems are stressed and inherently complex. Section 136 of the Mental Health Act is unusual being both an aspect of the Mental Health Act and a power of arrest. It has a long and controversial history related to concerns about who has been detained and how the section was applied. More recently, Section 136 has had a public profile stemming from the use of police cells as places of safety for young, mentally disturbed individuals. This paper explores the current state of health of this piece of legislation. Specifically, we consider whether alternative approaches are more suitable for those individuals in crisis and/or distress who come into contact with the police. This requires careful thought as to the proper role of both health and criminal justice professionals who are daily grappling with an ethically contentious domain of multiagency work.

What do general psychiatrists do? A question posed to medical students and the general population.

BACKGROUND: Misconceptions about the role of a psychiatrist are anecdotally widespread but have been under researched. AIMS: This study aimed to establish views on training and working in psychiatry amongst preclinical medical students at a South London Medical School and amongst a general public sample. METHODS: A semi-structured online questionnaire was used to survey medical students, with a similar paper questionnaire being used to survey members of the public in a general practice waiting room using a convenience sampling method. RESULTS: Strikingly, the majority of the public thought that psychiatrists did not need a medical degree (54%) or postgraduate training (56%). There were significant misconceptions about treatments used in mental health, for example 16% of the public sample thought psychiatrists never use medication and 31% of medical students (and 14% of the public) thought psychiatrists never use electroconvulsive therapy (ECT). In response to "do you believe a psychiatrist is able to know what people are thinking?", 45% of students and 57% of the public answered "sometimes". CONCLUSION: The results have important implications for public education, as lack of awareness about psychiatry may inhibit help seeking for mental illness, and have a negative impact on recruitment to psychiatry amongst medical students.

Exploration of staff attitudes and experiences towards mixed- and single-sex wards in the National Secure Forensic Service for Young People.

Mixed-sex wards in adult forensic secure services have been abolished and replaced by single-sex services. The National Secure Forensic Service for Young People (NSFSYP) continues to use a mixture of single-sex male and mixed-sex wards. This study aimed to explore staff experiences and attitudes towards placing young people in mixed- or single-sex wards in the NSFSYP. Mixed methodology was adopted in the form of focus groups (qualitative) and questionnaires (semi-quantitative). Content analyses of the qualitative data revealed five themes: care of female patients, normalization, safety, commissioning and social representation of women. The questionnaire was developed from the qualitative findings and comprised 22 statements measuring attitudes towards mixed- and single-sex wards. One hundred and forty-five questionnaires were returned: a 44% total response rate. Overall, the responses to the questionnaire confirmed the focus group data. There were statistically significant differences in responses between staff working on mixed- and single-sex wards. Staff working on mixed-sex wards felt that mixing genders on wards is a crucial part of adolescent forensic inpatient treatment. For them, mixed wards provide a more developmentally appropriate environment for young people. The needs of female patients broaden the debate beyond segregating and mixing gender.

No decision about me without me? Shared decision-making in mental healthcare.

Is there really 'no decision about me without me'? This concept of shared decision-making is increasingly supported in the UK National Health Service and is to be welcomed. But the attempt to apply guidelines based on Western physical health settings to all psychiatric patients, across different cultural backgrounds, is problematic. Methodological difficulties when trying to apply the gold standard of randomised controlled trials to the real-life settings of mental health should be considered, especially when many patients with serious mental health problems are excluded, having been deemed to 'lack capacity'. Should guidelines originating in physical healthcare settings really be applied to mental health ones? Does one size really fit all?

A retrospective cohort study describing characteristics of those repeatedly detained under Section 136 of the Mental Health Act over a 5-year period and the association with past abuse.

Individuals repeatedly detained under Section 136 (S136) of the Mental Health Act account for a significant proportion of all detentions. This study provides a detailed analysis of those repeatedly detained ('repeat attenders') to a London Mental Health Trust, identifying key demographic profiles when compared to non-repeat attenders, describing core clinical characteristics and determining to what degree a past history of abuse might be associated with these.All detentions to the S136 suite at South West London and St George's Mental Health NHS Trust over a 5-year period (2015-2020) were examined. Data were collected retrospectively from electronic records. A total of 1767 patients had been detained, with 81 patients identified as being a 'repeat attenders' (having had > = 3 detentions to the S136 suite during the study period). Repeat attenders accounted for 400 detentions, 17.7% of all detentions.Repeat attenders included a higher proportion of females (49.4%, p = 0.0001), compared to non-repeat attenders, and a higher proportion of them were of white ethnicity (85.2%, p = 0.001). 52 (64%) patients reported being a victim of past abuse or trauma. Of repeat attenders who reported past abuse or trauma, a high proportion had diagnoses of personality disorders, with deliberate self-harm as the most common reason for detention. They were more commonly discharged home with community support, rather than considered for hospital admission. In light of these findings, this paper discusses support potential strategies for those most vulnerable to repeated S136 detention, thereby minimising the ever-growing number of S136 detentions in the UK.

Effect of digital psychoeducation and peer support on the mental health of family carers supporting individuals with psychosis in England (COPe-support): a randomised clinical trial.

BACKGROUND: Psychoeducation delivered face-to-face is effective in alleviating mental health morbidities in family carers of individuals with psychosis. However, research in such interventions delivered online is scarce. We evaluated the effectiveness of a digital multicomponent intervention-COPe-support-in improving carers' mental wellbeing and caregiving-related outcomes. METHODS: In this two-arm, individually randomised, superiority trial, people aged 18 years or older who provided at least weekly support in any format for a relative or close friend affected by psychosis across England were randomly assigned (1:1) to either COPe-support or a passive online information resource using an independent online system. Participants were recruited through 30 mental health UK National Health Service trusts. The study team were masked to allocation and assessment of outcomes as all data collection took place online. Participants had access to either condition for 40 weeks and were advised to spend at least half an hour per week over the initial 20 weeks to go through materials at their own pace and to allow time to integrate knowledge and skills learned into practice. It was not feasible to mask participants or the online facilitator to intervention allocation. COPe-support provided psychoeducation on psychosis-related caregiving strategies and forums with professionals and other carers, and the control intervention comprised a passive online information resource. The primary outcome at 20 weeks was mental wellbeing measured by the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS; minimally clinically important difference [MCID] 3). This trial is registered with ISRCTN, 89563420. FINDINGS: Between March 1, 2018, and Feb 14, 2020, 407 participants were randomly assigned, with 204 allocated to COPe-support and 203 allocated to control. The participants (mean age 53·1 years, SD 13·2) were mostly female (330 [81%] of 407 participants) and White (359 [88%] of 407 participants). 346 (85%) of 407 participants provided primary endpoint data, 174 (85%) of 204 participants in the COPe-support group and 172 (85%) of 203 participants in the control group. The mean WEMWBS score at 20 weeks was 44·5 (SD 8·31) for the COPe-support group and 43·3 (9·19) for the control group. We found no evidence of a difference in wellbeing between the two groups (adjusted mean difference 0·37, 95% CI -1·14 to 1·88; p=0·63). In the COPe-support group, 106 (52%) of 204 participants met the complier definition of a minimum of two logins in separate weeks. The complier average causal effect analysis increased the difference in WEMWBS scores (adjusted difference 0·83, 95% CI -1·45 to 3·11; p=0·47), but this was lower than the MCID. There were no adverse events. INTERPRETATION: Our findings did not support the use of COPe-support over a passive online information resource. However, further research to optimise digital interventions adjunctive to face-to-face support for carers remains important. FUNDING: National Institute for Health Research.

A comparison of multiple mini-interviews and structured interviews in a UK setting.

INTRODUCTION: The multiple mini-interview (MMI) has been shown to be a valuable tool to aid the selection of medical students. The increasing body of research data so far has not evaluated this approach in the UK, where selection for medical training has traditionally included a single unstructured or structured interview. METHODS: MMI stations were developed and tested on volunteer candidates for admission to the MBBS 4 and MBBS 5 courses. Volunteers undertook their admissions interview before taking part in the MMI trial. Scores were compared between the two interview formats and any relationship with demographic details and the aptitude tests (UK Clinical Aptitude Test and Graduate Medical School Admissions Test) established. RESULTS: MBBS 4 applicants performed just as well on the MMI as they did on the traditional interview, with the MBBS 5 applicants performing better on the MMI. MBBS 4 and MBBS 5 candidates did equally well on the MMI. There was no difference in performance related to sex or age. DISCUSSION: MMIs are reliable, feasible and acceptable to both applicants and interviewers. Longitudinal research will shed more light on the validity of MMI as a way of measuring applicants' potential to become professional, successful doctors.

Are summer schools a way to improve recruitment in psychiatry?

Summer schools are traditionally used to encourage sixth form students to consider a career in medicine. Is it worth attracting students earlier in their school career, concentrating on psychiatry? Wyke et al describe an innovative project attempting to do just that.

Follow the money: how is medical school teaching funded?

Growing student numbers are producing greater demand for teaching, and resources allocated for education are being placed under increasing strain. The need for more student clinical placements and more clinician teaching time is expanding. Psychiatrists have successfully drawn attention to the importance of parity between mental and physical illness. We now have a responsibility to ensure enhanced opportunities to teach psychiatry to our medical students. This is set against a background of an increasing number of psychiatry consultants leaving the profession and an already stretched National Health Service environment. Many consultants contribute to teaching but do not have this activity included in their job plans. Although clinics and clinical meetings are inevitably slower when students are present, there is often no backfill provided. As outlined below, trusts receive substantial funding to cover costs related to the teaching of medical students, but most of us don't know what actually happens to this money. Here, we discuss how teaching is currently funded and make recommendations regarding improving accountability.

Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: An ethical, legal, and practical challenge.

Psychiatric inpatients are particularly vulnerable to the transmission and effects of COVID-19. As such, healthcare providers should implement measures to prevent its spread within mental health units, including adequate testing, cohorting, and in some cases, the isolation of patients. Respiratory isolation imposes a significant limitation on an individual's right to liberty, and should be accompanied by appropriate legal safeguards. This paper explores the implications of respiratory isolation in English law, considering the applicability of the common law doctrine of necessity, the Mental Capacity Act 2005, the Mental Health Act 1983, and public health legislation. We then interrogate the practicality of currently available approaches by applying them to a series of hypothetical cases. There are currently no 'neat' or practicable solutions to the problem of lawfully isolating patients on mental health units, and we discuss the myriad issues with both mental health and public health law approaches to the problem. We conclude by making some suggestions to policymakers.

Crossing the line--learning psychiatry at the movies.

Special Study Modules (SSMs) have developed in response to the General Medical Council's recommendations. St George's, University of London runs a 'Psychiatry and Film' SSM for medical students on the 5-year MBBS course. Many films have plots or characters that have a mental illness. Psychiatry & filmmaking share certain skills. Both seek to understand character, motivation and behaviour. Cinema therefore has the potential to be a useful tool for medical educational purposes. Specific to psychiatry, themes such as the accuracy of portrayals of different mental illness, the psychiatrist/patient relationship and living with a mental illness can be explored. General issues such as the role of the psychiatrist in society, medical ethics, professionalism and stigma can also be usefully highlighted for consideration and debate. This may encourage medical students to consider psychiatry as a potential career specialty and help reduce negative attitudes to mental illness.

Disengagement from mental health services. A literature review.

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

A retrospective cohort study describing the characteristics of patients under 18 years old in one section 136 suite.

Section 136 of the Mental Health Act 1983 is an authority allowing police officers to remove a person 'who appears to him to be suffering from mental disorder' from a public area. There has been much media coverage regarding the inappropriate detention of minors under section 136 and the suggestion that many were taken to police cells, as there were no suitable places of safety. Although previous studies describe characteristics of a typical individual detained under section 136, few distinguish the differences between adults and adolescents. Profiling these adolescents can help to identify adolescents at risk, allowing for earlier intervention and prevent the inappropriate detention of individuals. Data were collected retrospectively for all patients under 18 years of age who were brought to a section 136 suite in south-west London over a five-year period. The typical profile of an adolescent presenting to this suite was a 16-year-old female of white ethnicity who was sectioned in a public area due to attempted suicide or deliberate self-harm. The individual is more likely to have mental or behavioural difficulties, a history of abuse, be under the care of local authorities and have had previous convictions compared to adolescents in the general population.