A hospital-wide group approach to promote open dialogues of workplace issues and staff wellbeing with Schwartz Rounds.

OBJECTIVES: This study aims to explore the feasibility and impact of Schwartz Rounds® led by psychiatrists/mental health professionals in an urban Australian public hospital setting and to develop strategies for optimising participants' experiences. METHODS: Being a mixed-methods study collecting qualitative and quantitative data through post-Rounds evaluation surveys, this study thematically analysed responses from 105 participants attending four consecutive monthly Rounds between February and May 2023 to assess the perceived benefits and challenges of Schwartz Rounds. RESULTS: Respondents highly valued the Rounds and felt cared for by the healthcare organisation. Themes related to perceived benefits included (i) Connectedness and shared experience; (ii) Understanding other professionals; (iii) Normalisation of emotional distress, validation and a safe space for vulnerability; and (iv) Fostering authenticity and humanitarian aspects of healthcare. Challenges included (i) Fear of exposure and judgment; (ii) Emotional discomfort; (iii) Unfamiliarity with reflection; and (iv) Safety concerns. CONCLUSIONS: This study suggests acceptability and feasibility of implementing Schwartz Rounds within an Australian public health setting, particularly when facilitated by skilled mental health professionals. The outcomes provide preliminary support for the use of group interventions to enhance staff collegiality and culture in healthcare settings, thereby addressing critical needs for health professional wellbeing.

Meditation Moderates the Relationship between Insecure Attachment and Loneliness: A Study of Long-Term Care Residents in Thailand.

Background and Objectives: Loneliness is prevalent among residents of long-term care settings, posing significant challenges to their mental wellbeing. Insecure attachment has been identified as a contributing factor to loneliness in this population. Previous research has suggested that meditation may have beneficial effects on mental health outcomes. This study aimed to examine the relationship between meditation, insecure attachment, and loneliness among residents of long-term care facilities in Thailand. Specifically, the study sought to investigate the moderating effect of meditation on the association between insecure attachment (both avoidance and anxiety) and loneliness. Materials and Methods: A cross-sectional study was conducted involving 236 residents living in long-term care homes in Thailand. Participants completed self-report measures including the 18-item Revised Experience of Close Relationship questionnaire (to assess attachment anxiety and avoidance), the Inner Strength-Based Inventory (to measure meditation practice), and the 6-item Revised Version of the University of California Los Angeles Loneliness Scale. Moderation analyses were performed to explore the role of meditation in the relationship between insecure attachment and loneliness. Results: The mean age of participants was 73.52 years, with females accounting for 57.6% of the sample. Among the participants, 58.4% reported engaging in meditation, with practice frequency ranging from often to daily. The mean meditation score was 2.92 out of 5, indicating regular but not daily practice. Meditation was found to moderate the relationship between insecure attachment (both avoidance and anxiety) and loneliness. Specifically, the moderation effect between attachment anxiety and loneliness was significant (B = 0.44, SE = 0.21, 95% CI [0.30, 0.86]), as was the interaction effect between attachment anxiety and loneliness (B = -0.34, SE = 0.17, 95% CI [-0.67, -0.02]). Conclusions: The findings suggest that the impact of meditation practice on loneliness is influenced by an individual's attachment dimension. Meditation demonstrates a moderating effect on attachment avoidance, anxiety, and loneliness, with variations observed in the direction of these effects. The clinical implications of these findings and recommendations for further research are discussed.

A qualitative study of multiple voices to inform aftercare services for older persons following self-harm.

OBJECTIVES: Self-harm and suicide are closely related in older adults, highlighting the opportunity for Aftercare interventions in targeted suicide prevention. The study aims were to explore strengths and shortfalls of current Aftercare services for older adults from the perspective of key stakeholders and researchers; and inform a set of guiding principles for older persons' Aftercare. METHODS: Semi-structured interviews were undertaken with a convenience sample of older people with lived experience of self-harm, clinicians and suicide researchers (n = 22). Interviews were focussed on current practice (strengths and limitations), potential improvements, and identifying the core components of an acceptable Aftercare model. Interviews were audio-recorded, transcribed and subjected to a reflexive thematic analysis grounded in interpretive description. RESULTS: Current practice strengths included validation, a person-centred approach and optimising aftercare delivery. Limitations included ageism, practical limitations (lack of service awareness, fragmented service provision, barriers to access, and traumatising approaches), and limited services, funding and training. Overarching themes included anti-ageism; anti-stigma; empowerment and agency; conveying hope; patience and pace; accessible; and finding purpose: connections and meaningful activity. CONCLUSIONS: Older people who have self-harmed have complex, individualised needs. They sit within intersecting systems traversing healthcare, support services, family, and the social environment. Systemic, coordinated Aftercare founded upon core principles of anti-ageism, anti-stigma, partnership, empowerment, accessibility and provision of connections and meaning are needed.

Waiting for guardianship in a public hospital geriatric inpatient unit: a mixed methods observational case series.

BACKGROUND: Patients in acute hospital settings waiting for guardianship and financial management (FM) hearings experience extended length of stay (LOS), with known consequences for frail elderly. This, together with universal agreement that substitute decision-making is a last resort measure, an imperative exists to examine guardianship and FM applications made from within hospital for geriatric inpatients. AIMS: This study aims to examine processes around Guardianship applications in a public hospital Geriatric inpatient setting including times to, reasons for and outcomes of referral; and to explore the content of the medical records in relation to criteria for application. METHOD: This was a mixed methods observational case series using descriptive data supplemented by qualitative case-note analysis of inpatients referred for guardianship (with/without FM) from 2018 to 2020 in a New South Wales Geriatric Medicine inpatient unit. Medical records were examined for evidence of operationalised criteria for guardianship, aligned with disability, capacity and need/risk common to most Australian jurisdictions. RESULTS: Of 45 patients with guardianship applications, 98% were granted guardians and 33 of 37 (89%) FM applications. Multiple risks underpinned applications, most commonly frequent falls (49%) and medication mismanagement (49%). Although only 29% were in receipt of services preadmission, 98% were discharged to residential care. Average hospital LOS was 70 days (interquartile range, 35), contributed to by delays between admission and decision to apply for guardianship/FM (median, 28 inpatient days) and uncertainties around or lack of documented capacity assessments. CONCLUSION: This study identifies potential points along pathways towards guardianship in hospital settings, which might be targeted to streamline if not divert some of these applications. Points of intervention include at initiation of applications, with consideration of alternatives to substitute decision-making by addressing patient needs and using supported decision-making, while improving clinician understanding of capacity assessment and guardianship.

The perspectives of hospital doctors about end-of-life care in people with mental illness: an observational pilot study.

BACKGROUND: Negative attitudes towards people living with mental illness (PLWMI), defined here as mentalism, are a major contribution to health care inequity, which may extend into end-of-life care. There is a clear need for investigation of the attitudes of doctors towards PLWMI at the end of life as doctors may lead processes of care that contribute to this inequity. AIMS: The aim of this pilot study is to examine the perspectives of hospital-based doctors regarding end-of-life care and medical decision-making in PLWMI. METHODS: A survey was created to explore whether mentalism is present in the perspectives of hospital doctors regarding end-of-life care for PLWMI. The survey included demographic characteristics of participants and questions comprising statements and vignettes that required agree/disagree responses. Descriptive statistics were used to summarise responses, and chi-square tests examined associations with demographic variables. RESULTS: The survey was commenced by 48 hospital-based doctors and completed by 45. Descriptive statistics indicated that mentalism is present in the attitudes of hospital doctors regarding end-of-life care of PWLMI, with 47 of 48 participants (98%) endorsing at least one mentalist response. One significant association found that psychiatrists and psychiatry trainees were less likely to endorse a stereotype response in one vignette. CONCLUSIONS: This preliminary study addresses a gap within the literature on the potential contribution of mentalist attitudes in doctors to the poorer end-of-life care outcomes for PLWMI. The findings highlight the need for further study of this topic and suggest a role for targeted medical education in the pursuit of health care equality for PLWMI.

Objections to assisted dying within institutions: systemic solutions for rapprochement.

In this Matters Arising article, we outline how the recent article "The impact on patients of objections by institutions to assisted dying: a qualitative study of family caregivers' perceptions" (White et al., 2023 Mar 13;24(1):22) informed Voluntary Assisted Dying (VAD) implementation in our large Australian public health setting, where objections do not emanate from, but within, the institution. In reporting the harms to patients and caregivers created by institutional objection, White et al. provide an evidenced-based road map for potential potholes or risks associated with VAD implementation. We discuss the complexities emerging from the diverse views of health professionals and the ethical tensions arising from such, especially within certain specialties, and how we developed systemic strategies that support patients, caregivers and staff alike. We highlighted the need to shift from "Do you support VAD?" to "How can we support you as healthcare professionals to integrate VAD into your practice, in a way that complies with the legislation, meets the needs of patients and caregivers, and feels safe and does not compromise your moral stance?"

An innovative Australian doctors' health service: using systems therapy to work with individual medical leaders in an acute public health setting.

OBJECTIVE: To describe an innovative doctors' health service (Professional Support Unit) utilising systems therapy to support individual medical leaders across an Australian local public health district. METHOD: Therapeutic interventions were informed by systems theory, the study of social systems, coherent entities with hierarchical orders united by organising relations of rules, roles, structures and alliances. Systems therapy addresses these relations to effect change. Working with leaders individually was based on the premise of effecting change in the system by changing part of the system, particularly the 'decider subsystem' of the medical lead. RESULTS: Support was provided to 30 medical leaders (50% of potential cohort). All but five self-referred with zero dropouts. Referrals snowballed gradually and exponentially following psychoeducation sessions normalising struggling and seeking help. Diversity of themes presented or emerging included requests for: (i) psychological support for lead/family, or staff/family; (ii)didactic sessions regarding impairment, ageing doctor, performance management and mental health first aid for doctors; (iv) anger management; (v) difficult staff; and (vi) being undermined or placed in untenable positions. Interventions were accordingly diverse and tailored. A vulnerable-resilience model was developed with practical tips. CONCLUSIONS: Supporting medical leaders using therapeutic interventions grounded in systems theory may go towards addressing organisational duty of care to maintain safe work systems.

Beyond burnout II: A case series of doctors seen in a new publicly funded doctors' mental health service.

OBJECTIVE: Doctors' mental health has received increased focus recently and has been met with a variety of systemic responses. A Professional Support Unit (PSU) in a public hospital was established to address service gaps. This paper aims to describe the care of doctors referred to this service. METHODS: Participants in the first four cases were referred to the PSU and assessed by the first author. RESULTS: The cases revealed: (i) variety of referral sources, symptom presentations and backgrounds of doctors referred to a dedicated doctors' health service; and (ii) the person-centred, multi-modal treatments and adjunctive services required. CONCLUSION: Doctors' mental health is an urgent priority, with direct impacts on patient safety and care. The mix of patients presented here suggest difficulties beyond burnout and highlight the workings of a new service model designed to complement existing services in the Australian context.

Beyond burnout I: Doctors health services and unmet need.

OBJECTIVES: Doctors' mental health has received renewed attention given the epidemic of burnout, high suicide rates and the recent pressures of the COVID-19 pandemic. Internationally, various service designs and primary prevention initiatives have been trialled to address these needs. Systemic barriers such as stigma as well as individual characteristics of doctors have historically prevented access to mental health services. This paper outlines the Australian service context from which a new publicly funded doctors' mental health programme emerged. METHODS: A narrative review of current services and a description of the challenges is outlined. RESULTS: A picture of urgency and unmet needs emerged with particular challenges, such as the need for privacy. CONCLUSIONS: Doctors' mental health is an urgent priority with direct impacts on patient safety and care. The complex context and the unmet need suggest the focus must go far beyond burnout and has prompted the establishment of a new service model designed to complement existing services in the Australian context, to be described in a sister paper.

Educating Crisis Supporters About Self-Harm and Suicide in Older Adults.

OBJECTIVES: This study aimed to describe existing knowledge of crisis supporters (volunteers responding to crisis calls/texts/messages) regarding self-harm and suicide in older adults and investigate knowledge translation through use of a novel online adaptive learning tool. METHODS: The online educational tool was tested in an Australian national sample of crisis supporters (trained volunteers) aged 18+. Knowledge Transfer was evaluated utilizing a pre/post intervention methodology for data collection. The collaboratively developed online educational tool comprised a pre-test (10 questions), middle learning module (individualised for participant's incorrect pre-test responses) and post-test (10 questions) on suicidal behaviours in older adults. Data analysed included the demographic characteristics of the participants, individual question scores, and summed pre- and post-tests scores. Group differences in change scores were assessed with either one-way between subjects ANOVA or independent samples t-test, depending on the number of groups within each variable. Pre-post education comparisons on individual change in scores were made using a paired samples t-test. Statistical significance was defined as p <0.05. RESULTS: 104 crisis supporters completed the tool (pre-test, middle lesson and post-test). There was significant improvement in knowledge of crisis supporters after the intervention (pre-test scores Mean (M) = 4.56, SD = 1.62 and post-test scores M = 7.61, SD = 1.60; t (103) = 17.242, p <0.001.). CONCLUSION: Dedicated training about suicidal behaviors in older adults is needed given their high rates of suicide and differing underlying reasons and needs compared to younger adults.

Development of the Story Telling Examination for Early Mild Cognitive Impairment (Pre-Mild Cognitive Impairment) Screening.

INTRODUCTION: Cognitive function prior to mild cognitive impairment (MCI) has become a burgeoning interest. Tools used to detect this early period before MCI are being pilot-tested. This study aimed to develop a new test to detect pre-MCI and to examine its content validity and feasibility. METHODS: The Story Telling Examination for Early MCI Screening (STEEMS), an audio cognitive test, was developed. It covers ten cognitive domains, e.g., executive function, language fluency, abstract reasoning. Face and content validity were examined by experts in geriatric psychiatry and psychology. The content validity index was 1.00. STEEMS comprised 12 items with 2-4 types of scoring. The tool was further examined in 16 pilot samples for feasibility among healthy participants having no cognitive impairment (Montreal Cognitive Assessment [MoCA] test score ≥25, Mini-Cog ≥3) and no depressive symptoms (Geriatric Depression Scale <6). RESULTS: The 16 healthy older individuals aged 59-73 years, mean age was 65.06 ± 4.07 years, were predominantly males (68.8%). STEEMS scores ranged from 10 to 25, with a mean of 18.38 (SD = 4.2). Thirteen percent obtained 100% correct on the STEEMS, 63% scored 68-92% correct, and 25% scored 40-60% correct. The pre-MCI scores are illustrated by a bell curve's graphical depiction, suggesting a normal distribution probability distribution. Correlation between STEEMS and MoCA test scores was observed. STEEMS showed to be feasible for early elderly or late adults as being brief and easy to understand. The time spent to administer was predictably less than 7 min. DISCUSSION/CONCLUSION: STEEMS could potentially serve as a tool for pre-MCI screening. Further study and investigation in a larger population are required.

A systematic review of evidence-based aftercare for older adults following self-harm.

OBJECTIVE: Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies. METHODS: Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently. RESULTS: Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs. CONCLUSION: Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Imposter syndrome in doctors beyond training: a narrative review.

OBJECTIVE: To undertake a narrative literature review of imposter syndrome (IS) in doctors beyond training. METHOD: Twelve studies met inclusion criteria from a systematised search of three databases. RESULTS: There is a paucity of literature on IS, although it has been observed across a diverse range of specialties. IS appears to be more common in female doctors but is also seen amongst male doctors. IS impacts career progression, leadership and mental health. CONCLUSIONS: IS causes professional and personal detriment. Solutions must include institutional changes to foster safer workplaces and to address systemic barriers to help-seeking and peer support. Systemic interventions are the only solution to the systemic drivers of IS.

Invisible and at-risk: older adults during the COVID-19 pandemic.

During the COVID-19 pandemic the risks to older adults of systemic abuse and neglect have become amplified, alongside increasing abuse and neglect in the community. Novel risks have also evolved involving cybercrime and the use of remote technologies in health and social care related to the pandemic. This commentary brings together lessons to be learned from these developments and initial ideas for actions to mitigate future risks.

The Human Right to Justice for Older Persons With Mental Health Conditions.

This article explores the nature and extent of barriers to access to justice that older persons experience, including those with mental health conditions. It finds that access to justice-the right to fair, prompt and responsive decisions by administrative decision-makers and equal access to courts and tribunals to obtain timely and effective remedies-is not only an important right in itself but also enables the enjoyment of many other human rights. Yet older persons, particularly those with mental health conditions, face a significant "justice gap." Ageist attitudes, laws and practices interact with other forms of bias such as mentalism, sexism, ableism, racism, homophobia, and heterosexism exacerbating older persons' disadvantage and marginalization, particularly those with mental health conditions, and older indigenous persons. These discriminatory practices, together with the phenomena of elder abuse, all severely limit older persons' access to timely and responsive justice. International and national standards, both general and specific to older persons, have been shown to be inadequate to respond to this justice gap. An international standard in the form of a binding legal obligation that specifically addresses older persons' rights of access to justice is needed urgently as part of a new international treaty on the human rights of older persons.

The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well.

The human right to a good death and dying well is as important as the right to life. At stake at the end of life are human rights to dignity, autonomy, self-determination and respect for will and preferences, equitable access to quality health care that is needs-based, and respect for family and relationships. Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to "bad deaths" due to violations of these rights. In this paper we explore why this is so and examine existing and potential solutions. A human rights-approach to end-of-life care and policy for older persons with mental health conditions and psychosocial disability is one that is needs-based, encompassing physical and mental health, palliative care, social, and spiritual support services provided in the context of inclusive living. Most importantly, end of life care must be self-determined, and not "one size fits all." An important remedy to existing violations is to strengthen human rights frameworks to cater specifically to older persons' needs with a UN convention on the rights of older persons. Finally, as health professionals we have important contributions to make at the coalface by accepting our responsibilities in the area of death and dying. With the concept of the palliative psychiatrist gaining traction and recognition that death is our business, we add that human rights is also our business.

Ageism and the State of Older People With Mental Conditions During the Pandemic and Beyond: Manifestations, Etiology, Consequences, and Future Directions.

The pandemic has put the spotlight on older people and on the topic of ageism. In early 2021, a call was made for input into the Thematic Report on Ageism and Discrimination to inform the United Nations Independent Expert on the Rights of Older Persons' forthcoming report to the 48th session of the Human Rights Council. The aim of this paper is to articulate the International Psychogeriatric Association (IPA) and the World Psychiatric Association Section of Old Age Psychiatry (WPA-SOAP) response to this call. This brief statement on ageism with a special focus on older people with mental health conditions is divided into three sections. We start by outlining the various manifestations of ageism in varied contexts and countries with a primary focus on the pandemic. Possible consequences of ageism with a focus on older people's mental health and well-being are outlined. We conclude by discussing ways to overcome ageism and reduce its occurrence, especially during times of extreme conditions.

Is Suicide the End Point of Ageism and Human Rights Violations?

Ageism and human rights violations may pervade each of the potential factors underlying suicidal ideation or behavior in older persons, including physical and mental health, disability, relationships, and social factors. We outline how infringements of human rights and ageism may create or exacerbate risk factors associated with suicide in older persons. Strategies to address these issues are discussed, including tackling ageism, psychosocial interventions and education. A United Nations convention on the rights of older persons would create a uniform standard of accountability across health and social systems. Future studies are needed to evaluate the effects of alleviating ageism and human rights violations on suicide.

Understanding Barriers to the Realization of Human Rights Among Older Women With Mental Health Conditions.

There is increasing emphasis in research and at the level of international human rights bodies such as the United Nations on the gendered contours of age-based disadvantage and discrimination, and the cumulative effects of gender inequalities over the life-course on outcomes in later life. However, to date, the role of mental health in shaping the age/gender nexus in the realization of human rights has received little attention. In response, this paper aims to 1) elucidate the economic, social and cultural disadvantages and discrimination faced by older women living with mental health conditions; and 2) identify opportunities to protect their human rights. It concludes that older women face inequalities and disadvantages at the intersections of age, gender, and mental health and wellbeing that compromise their capacity to age well, illuminating the urgent need for a UN Convention on the Human Rights of Older Persons that considers the role of mental health in shaping the realization of human rights among older people.

Sexuality and the Human Rights of Persons With Dementia.

We explore barriers to enjoyment of human rights to sexuality of persons with dementia and remedies for addressing these. Enjoyment of sexuality is contingent upon actualization of rights to dignity, autonomy, respect for will and preferences, abuse safeguarding and equitable access to highest standards of sexual health. Persons with dementia living at home or in care face systemic barriers to enjoyment of sexuality fueled by ageism, apathy and ignorance, compounded by complex legal barriers in relation to consent. Such challenges can be tackled with awareness raising and education of care staff, families and physicians, including training for capacity assessment with dimensional, noncategorical conceptualization of capacity, leaving room for supported decision-making. These measures, together with strengthened legislative and human rights frameworks to cater to the specific needs of older people, may allow people to live well with dementia and exercise their human rights to enjoy sexuality in a safe and lawful manner.