The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses.

AIMS: Community treatment orders have been introduced in many jurisdictions with increasing use over time. We conducted a rapid umbrella review to synthesise the quantitative and qualitative evidence from systematic reviews and/or meta-analyses of their potential harms and benefits. METHODS: A systematic search of Medline, PubMed, Embase and PsycINFO for relevant systematic reviews and/or meta-analyses. Where available, participants on community treatment orders were compared with controls receiving voluntary psychiatric treatment. This review is registered with PROSPERO (CRD42023398767) and the Open Science Framework (https://osf.io/zeq35). RESULTS: In all, 17 publications from 14 studies met the inclusion criteria. Quantitative synthesis of data from different systematic reviews was not possible. There were mixed findings on the effects of community treatment orders on health service use, and clinical, psychosocial or forensic outcomes. Whereas uncontrolled evidence suggested benefits, results were more equivocal from controlled studies and randomised controlled trials showed no effect. Any changes in health service use took several years to become apparent. There was evidence that better targeting of community treatment order use led to improved outcomes. Although there were other benefits, such as in mortality, findings were mostly rated as suggestive using predetermined and standardised criteria. Qualitative findings suggested that family members and clinicians were generally positive about the effect of community treatment orders but those subjected to them were more ambivalent. Any possible harms were under-researched, particularly in quantitative designs. CONCLUSIONS: The evidence for the benefits of community treatment orders remains inconclusive. At the very least, use should be better targeted to people most likely to benefit. More quantitative research on harms is indicated.

A longitudinal study of the impacts of a stay in a Prevention and Recovery Care service in Victoria, Australia.

BACKGROUND: Prevention and Recovery Care services are residential sub-acute services in Victoria, Australia, guided by a commitment to recovery-oriented practice. The evidence regarding the effectiveness of this service model is limited, largely relying on small, localised evaluations. This study involved a state-wide investigation into the personal recovery, perceived needs for care, well-being and quality-of-life outcomes experienced by Prevention and Recovery Care services' consumers. METHODS: A longitudinal cohort design examined the trajectory of self-reported personal recovery and other outcomes for consumers in 19 Victorian Prevention and Recovery Care services over 4 time points (T1 - 1 week after admission; T2 - within 1 week of discharge; T3 - 6 months after discharge; T4 - 12 months after discharge). T2-T4 time frames were extended by approximately 3 weeks due to recruitment challenges. The Questionnaire about the Process of Recovery was the primary outcome measure. RESULTS: At T1, 298 consumers were recruited. By T4, 114 remained in the study. Participants scored higher on the Questionnaire about the Process of Recovery at all three time points after T1. There were also sustained improvements on all secondary outcome measures. Improvements were then sustained at each subsequent post-intervention time point. Community inclusion and having needs for care met also improved. CONCLUSION: The findings provide a consistent picture of benefits for consumers using Prevention and Recovery Care services, with significant improvement in personal recovery, quality of life, mental health and well-being following an admission to a Prevention and Recovery Care service. Further attention needs to be given to how to sustain the gains made through a Prevention and Recovery Care service admission in the long term.

'Quitlink': Outcomes of a randomised controlled trial of peer researcher facilitated referral to a tailored quitline tobacco treatment for people receiving mental health services.

OBJECTIVE: The aim of this study was to test the effectiveness of a tailored quitline tobacco treatment ('Quitlink') among people receiving support for mental health conditions. METHODS: We employed a prospective, cluster-randomised, open, blinded endpoint design to compare a control condition to our 'Quitlink' intervention. Both conditions received a brief intervention delivered by a peer researcher. Control participants received no further intervention. Quitlink participants were referred to a tailored 8-week quitline intervention delivered by dedicated Quitline counsellors plus combination nicotine replacement therapy. The primary outcome was self-reported 6 months continuous abstinence from end of treatment (8 months from baseline). Secondary outcomes included additional smoking outcomes, mental health symptoms, substance use and quality of life. A within-trial economic evaluation was conducted. RESULTS: In total, 110 participants were recruited over 26 months and 91 had confirmed outcomes at 8 months post baseline. There was a difference in self-reported prolonged abstinence at 8-month follow-up between Quitlink (16%, n = 6) and control (2%, n = 1) conditions, which was not statistically significant (OR = 8.33 [0.52, 132.09] p = 0.131 available case). There was a significant difference in favour of the Quitlink condition on 7-day point prevalence at 2 months (OR = 8.06 [1.27, 51.00] p = 0.027 available case). Quitlink costs AU$9231 per additional quit achieved. CONCLUSION: The Quitlink intervention did not result in significantly higher rates of prolonged abstinence at 8 months post baseline. However, engagement rates and satisfaction with the 'Quitlink' intervention were high. While underpowered, the Quitlink intervention shows promise. A powered trial to determine its effectiveness for improving long-term cessation is warranted.

Creating "an oasis of hope, inclusion and connection": students and stakeholders' experiences of a pilot Recovery College.

BACKGROUND: Recovery Colleges are an innovative approach to promoting personal recovery for people experiencing mental illness. AIMS: This study was to explore experiences of students, supporters, staff, educators and external stakeholders (i.e. partner organisations) of a pilot Recovery College in the Australian Capital Territory (ACTRC), and the impact of participation in the College for students and supporters. METHODS: ACTRC students, supporters, staff and educators, and external stakeholders were invited to participate in a mixed-method evaluation via an online survey, interviews and/or focus groups. The survey included questions regarding experiences and recovery-orientation of the College environment, and for students and supporters only, satisfaction with the College. Qualitative data from interviews and focus groups was inductively coded, thematically analysed and triangulated with survey responses. RESULTS: The findings suggest that the ACTRC provides a safe space, promotes meaningful connections within and beyond the college, and offers steppingstones supporting recovery and growth. Participants spoke positively about cross institutional partnerships and collaboration with several organisations within the ACT. CONCLUSIONS: This evaluation reiterates the role of Recovery Colleges as an innovative approach to promoting personal recovery for people living with mental illness. Adequate resourcing and collaboration are essential in realising the value of co-production whilst ensuring sustainability.

Professional care workforce: a rapid review of evidence supporting methods of recruitment, retention, safety, and education.

BACKGROUND: Across the care economy there are major shortages in the health and care workforce, as well as high rates of attrition and ill-defined career pathways. The aim of this study was to evaluate current evidence regarding methods to improve care worker recruitment, retention, safety, and education, for the professional care workforce. METHODS: A rapid review of comparative interventions designed to recruit, retain, educate and care for the professional workforce in the following sectors: disability, aged care, health, mental health, family and youth services, and early childhood education and care was conducted. Embase and MEDLINE databases were searched, and studies published between January 2015 and November 2022 were included. We used the Quality Assessment tool for Quantitative Studies and the PEDro tools to evaluate study quality. RESULTS: 5594 articles were initially screened and after applying the inclusion and exclusion criteria, 30 studies were included in the rapid review. Studies most frequently reported on the professional nursing, medical and allied health workforces. Some studies focused on the single domain of care worker education (n = 11) while most focused on multiple domains that combined education with recruitment strategies, retention strategies or a focus on worker safety. Study quality was comparatively low with a median PEDro score of 5/10, and 77% received a weak rating on the Quality Assessment tool for Quantitative Studies. Four new workforce strategies emerged; early career rural recruitment supports rural retention; workload management is essential for workforce well-being; learning must be contextually relevant; and there is a need to differentiate recruitment, retention, and education strategies for different professional health and care workforce categories as needs vary. CONCLUSIONS: Given the critical importance of recruiting and retaining a strong health and care workforce, there is an immediate need to develop a cohesive strategy to address workforce shortfalls. This paper presents initial evidence on different interventions to address this need, and to inform care workforce recruitment and retention. Rapid Review registration PROSPERO 2022 CRD42022371721 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022371721.

Evidence-based Recovery Colleges: developing a typology based on organisational characteristics, fidelity and funding.

PURPOSE: Recovery Colleges (RCs) have been implemented across England with wide variation in organisational characteristics. The purpose of this study is to describe RCs across England in terms of organisational and student characteristics, fidelity and annual spending, to generate a RC typology based on characteristics and to explore the relationship between characteristics and fidelity. METHODS: All RC in England meeting criteria on recovery orientation, coproduction and adult learning were included. Managers completed a survey capturing characteristics, fidelity and budget. Hierarchical cluster analysis was conducted to identify common groupings and generate an RC typology. RESULTS: Participants comprised 63 (72%) of 88 RC in England. Fidelity scores were high (median 11, IQR 9-13). Both NHS and strengths-focussed RCs were associated with higher fidelity. The median annual budget was £200,000 (IQR £127,000-£300,000) per RC. The median cost per student was £518 (IQR £275-£840), cost per course designed was £5,556 (IQR £3,000-£9,416) and per course run was £1,510 (IQR £682-£3,030). The total annual budget across England for RCs is an estimated £17.6 m including £13.4 m from NHS budgets, with 11,000 courses delivered to 45,500 students. CONCLUSION: Although the majority of RCs had high levels of fidelity, there were sufficiently pronounced differences in other key characteristics to generate a typology of RCs. This typology might prove important for understanding student outcomes and how they are achieved and for commissioning decisions. Staffing and co-producing new courses are key drivers of spending. The estimated budget for RCs was less than 1% of NHS mental health spending.

Constructing recovery: A Lived Experience and post-structuralist exploration of how the meaning of personal recovery and rehabilitation has changed over time.

OBJECTIVE: This article explores how the concept of 'recovery' has been much debated and often sits at odds with our notion of rehabilitation. METHOD: This article provides a Lived Experience and post-structural commentary on the ever-changing meaning of recovery and rehabilitation. RESULTS: Building on the contemporary Consumer Movement's use of the term recovery, this article explores how constructions of recovery try to create a boundary which stops people being invalidated based on their experience, or perceived experience, of mental distress. The concept of recovery has insufficiently influenced rehabilitation practices. Recovery is also frequently reappropriated, often with no or minimal consumer input, and reconstructed in line with notions of progress and improvement. CONCLUSION: People with Lived Experience have challenged the concept of rehabilitation; however, rehabilitation may still have relevance if it is redefined according to Lived Experience values and recovery-oriented practice.

Using a digital personal recovery resource in routine mental health practice: feasibility, acceptability and outcomes.

BACKGROUND: Digital technologies enable the dissemination of multimedia resources to support adults with serious mental illness in their self-management and personal recovery. However, delivery needs to accommodate engagement and accessibility challenges. AIMS: We examined how a digital resource, designed for mental health workers and consumers to use together in session, would be used in routine practice. METHODS: Thirty consumers and their workers participated. The web-based resource, Self-Management And Recovery Technology (SMART), was available to use within and between sessions, for a 6-month period. Workers initiated in-session use where relevant. Feasibility was explored via uptake and usage data; and acceptability and impact via questionnaires. A pre-post design assessed recovery outcomes for consumers and relationship outcomes for consumers and workers. RESULTS: In participating mental health practitioner-consumer dyads, consumers gave strong acceptability ratings, and reported improved working relationships. However, the resource was typically used in one-third or fewer appointments, with consumers expressing a desire for greater in-session use. Improvements in self-rated personal recovery were not observed, possibly contributed to by low usage. CONCLUSIONS: In-session use was found helpful by consumers but may be constrained by other demands in mental health care delivery: collaborative use may require dedicated staff time or more formal implementation.

A journey of living well: a participatory photovoice study exploring recovery and everyday activities with people experiencing mental illness.

BACKGROUND AND AIM: Engagement in everyday activities has been identified as an important element in personal recovery from the experience of mental illness and a key priority for service-users. This study explored the role of everyday activities in recovery. METHOD: This study used a photovoice participatory research. Twenty-one participants experiencing mental illness were recruited from a community-managed mental health service in Melbourne, Australia. Data collection included individual interviews and photovoice courses. The courses included group discussions and required participants to take photographs about their everyday activities that support recovery. A lived experience co-facilitator contributed to development and delivery of the course. The interviews and group discussions were transcribed verbatim and analysed using constant comparative methods. RESULTS: Recovery as a "journey of living well" was identified as the central theme that encompasses three interlinked categories: (1) living a life on hold; (2) choosing to recover; and (3) learning and navigating strategies. CONCLUSIONS: The findings suggest that recovery involves a range of experiences embedded in people's everyday lives. Recovery-oriented practice should provide opportunities for engagement in meaningful activities, to help consumers identify their potential and strategies to live well, and to adopt co-production at all levels.

Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia.

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in 'absences without permission' from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients 'escaping' from mental health wards, yet all may be counted as 'absent without permission' events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

Outcomes of Victorian Prevention and Recovery Care Services: A matched pairs comparison.

OBJECTIVE: In Victoria, Prevention and Recovery Care Services have been established to provide a partial alternative to inpatient admissions through short-term residential mental health care in the community. This study set out to determine whether Prevention and Recovery Care Services are achieving their objectives in relation to reducing service use and costs, fostering least restrictive care and leading to positive clinical outcomes. METHODS: We matched 621 consumers whose index admission in 2014 was to a Prevention and Recovery Care ('PARCS consumers') with 621 similar consumers whose index admission in the same year was to an acute inpatient unit and who had no Prevention and Recovery Care stays for the study period ('inpatient-only consumers'). We used routinely collected data to compare them on a range of outcomes. RESULTS: Prevention and Recovery Care Services consumers made less subsequent use of acute inpatient services and, on balance, incurred costs that were similar to or lower than inpatient-only consumers. They were also less likely to spend time on an involuntary treatment order following their index admission. Prevention and Recovery Care Services consumers also experienced positive clinical outcomes over the course of their index admission, but the magnitude of this improvement was not as great as for inpatient-only consumers. This type of clinical improvement is important for Prevention and Recovery Care Services, but they may place greater emphasis on personal recovery as an outcome. CONCLUSION: Prevention and Recovery Care Services can provide an alternative, less restrictive care option for eligible consumers who might otherwise be admitted to an acute inpatient unit and do so at no greater cost.

Advance Planning in Mental Health Care: The Trouble with Terminology.

Advance planning is increasingly being used in mental health care, particularly in the context of potential compulsory treatment. A variety of advance planning instruments may be used in health care settings and there has been confusion about the most appropriate language to describe them. This adds to confusion about whether an instrument is binding on health professionals or consumers and how the instrument might be disseminated. This column provides an overview and critique of current provisions in Australian law and of the key terms used.

Age-specific incidence of injury-related hospital contact after release from prison: a prospective data-linkage study.

BACKGROUND: In population studies, the risk of injury declines after early adulthood. It is unclear if a similar age difference in the risk of injury exists among people released from prison. METHODS: Prerelease survey data collected between 1 August 2008 and 31 July 2010, from a representative cohort of sentenced adults (≥18 years) in Queensland, Australia, were linked prospectively and retrospectively to person-level emergency department, inpatient hospital and correctional records. To ascertain predictors of injury-related hospital contact, we fit a multivariate Andersen-Gill model and tested the interactions between age group (<25 years, ≥25 years) and each variable. RESULTS: In 1307 adults released from prison, there were 3804 person-years of follow-up. The crude injury rate was 385 (95% CI 364 to 407) per 1000 person-years and did not differ according to age group. Factors associated with increased injury-related hospital contact included a history of mental illness, preincarceration injury, a history of incarceration, release from a short prison sentence (<90 days), being reincarcerated during follow-up and identifying as Indigenous. The effect of mental illness, risky alcohol use, prior incarceration and intellectual disability differed across age group and predicted increased risk of injury among people aged ≥25 years compared with their counterparts without these characteristics. CONCLUSIONS: Unlike in the general population where the risk of injury declines with age, older adults released from prison are at similar risk compared with their younger peers. Adults released from prison with mental illness, a history of injury-related hospital contact and who identify as Indigenous are particularly indicated groups for injury prevention.

'I'm proud of how far I've come. I'm just ready to work': mental health recovery narratives within the context of Australia's Disability Employment Services.

BACKGROUND: Employment is recognised as facilitating the personal and clinical recovery of people with psychosocial disability. Yet this group continue to experience considerable barriers to work, and, constitute a significant proportion of individuals engaged with Disability Employment Services (DES). Recognition of the role of recovery-oriented practice within DES remains limited, despite these approaches being widely promoted as best-practice within the field of mental health. METHODS: The Improving Disability Employment Study (IDES) aims to gather evidence on factors influencing employment outcomes for Australians with disability. Descriptive analysis and linear regression of IDES survey data from 369 DES participants, alongside narrative analysis of data collected through 56 in-depth interviews with 30 DES participants with psychosocial disability, allowed us to explore factors influencing mental health, well-being and personal recovery within the context of DES. RESULTS: Psychosocial disability was reported as the main disability by 48% of IDES respondents. These individuals had significantly lower scores on measures of mental health and well-being (44.9, 48.4 respectively, p ≤ 0.01), compared with respondents with other disability types (52.2, 54.3 p ≤ 0.01). Within this group, individuals currently employed had higher mental health and well-being scores than those not employed (47.5 vs 36.9, 55.5 vs 45.4 respectively, p ≤ 0.01). Building on these findings, our qualitative analysis identified five personal recovery narratives: 1) Recovery in spite of DES; 2) DES as a key actor in recovery; 3) DES playing a supporting role in fluctuating journeys of recovery; 4) Recovery undermined by DES; and, 5) Just surviving regardless of DES. Narratives were strongly influenced by participants' mental health and employment status, alongside the relationship with their DES worker, and, participants' perspectives on the effectiveness of services provided. CONCLUSION: These findings re-iterate the importance of work in supporting the mental health and well-being of people with psychosocial disability. Alongside access to secure and meaningful work, personal recovery was facilitated within the context of DES when frontline workers utilised approaches that align with recovery-orientated practices. However, these approaches were not consistently applied. Given the number of people with psychosocial disability moving through DES, encouraging greater consideration of recovery-oriented practice within DES and investment in building the capacity of frontline staff to utilise such practice is warranted.

Similarities and differences in people accessing prevention and recovery care services and inpatient units in Victoria, Australia.

BACKGROUND: There is an emerging international literature demonstrating clinical and cost-effectiveness of sub-acute residential mental health services. To date, however, there is limited information on the profile of consumers accessing these models of care. This study aimed to understand the profile of the population served by adult sub-acute residential mental health services in Victoria, Australia (known as Prevention and Recovery Care; PARC) and to compare PARC service consumers with consumers admitted to psychiatric inpatient units within public hospitals. METHOD: Using 5 years (2012-2016) of a state-wide database of routinely collected individual level mental health service data, we describe the socio-demographic and clinical profile of PARC service consumers compared to consumers of psychiatric inpatient units including for primary diagnosis and illness severity. Using admissions as the unit of analysis, we identify the characteristics that distinguish PARC service admissions from psychiatric inpatient admissions. We also examine and compare length of stay for the different admission types. RESULTS: We analysed 78,264 admissions representing 34,906 individuals. The profile of PARC service consumers differed from those admitted to inpatient units including for sex, age, diagnosis and illness severity. The odds of an admission being to a PARC service was associated with several socio-demographic and clinical characteristics. Being male or in the youngest age grouping (< 20 years) significantly reduced the odds of admission to PARC services. The presence of primary diagnoses of schizophrenia and related disorders, mood, anxiety or personality disorders, all significantly increased the odds of admission to PARC services. Predictors of length of stay were consistent across PARC and inpatient admission types. CONCLUSIONS: Our findings suggest PARC services may serve an overlapping but distinguishably different consumer group than inpatient psychiatric units. Future research on sub-acute mental health services should be cognizant of these consumer differences, particularly when assessing the long-term effectiveness of this service option.

Safewards Training in Victoria, Australia: A Descriptive Analysis of Two Training Methods and Subsequent Implementation.

Safewards is a psychosocial intervention designed to improve practice and staff-patient interactions in mental health wards. However, evidence regarding the impact of training on implementing change initiatives in this setting is mixed. Pre- and post-training surveys were completed by staff from 18 inpatient wards across seven health services in Victoria, Australia. Fidelity audits were undertaken to assess implementation of Safewards into routine practice. Staff knowledge, confidence, and motivation increased significantly from pre- to post-training, with no difference between two different methods of training. Most wards were implementing six or more of the interventions at the end of the trial. A structured approach to training, with flexibility of delivery options, produced positive changes in staff and translation to practice. Substantial investment in training from government and organizations appears to strengthen the uptake and impact of training, and the current study provides evidence that the interventions were implemented as intended. [Journal of Psychosocial Nursing and Mental Health Services, 58(12), 32-42.].

Key features of an innovative sub-acute residential service for young people experiencing mental ill health.

BACKGROUND: Numerous studies across international settings have highlighted a need to improve the appropriateness and continuity of services for young people experiencing mental ill health. This paper examines key features of a sub-acute youth mental health residential service model, Youth Prevention and Recovery Care (Y-PARC) service. Y-PARC provides up to 4 weeks care to 16 to 25 year-olds at risk of hospitalisation and to those transitioning out of hospital inpatient units. The research was conducted at one of three Y-PARCs located in Victoria, Australia. METHODS: This paper presents findings from analysis of two data sources collected during evaluation of a Y-PARC service in 2015-17. Routinely collected administrative data of Y-PARC residents (n = 288) were analysed and semi-structured interviews were conducted with 38 participants: a) former residents (n = 14); b) family members of group a) (n = 5); key stakeholders (n = 9); and, Y-PARC staff (n = 10 respondents in 3 group interviews). Analysis of the qualitative data was thematic and structured by the interview guide, which covered the key service aims. RESULTS: Consistent with the aims of the service, respondents described practice at Y-PARC that aligns with recovery-oriented care. Key features emphasised were: a safe and welcoming environment for residents and families; provision of person-centred care; promotion of autonomy and self-help; informal interactions with staff allowing for formation of naturalistic relationships; time spent with other young people with similar experiences; and, assurance upon exit that the 'door is always open.' High levels of satisfaction were reported. Outcomes described included: improved resilience; better understanding of mental health; the importance of seeking help; and, stronger connections to therapeutic services. Longer and multiple stays were associated with progressive and sustained change. Family members and stakeholders widely reported that the service fills a gap between community services and acute inpatient mental health hospital wards. Some challenging areas of practice identified included: integration of evidence-based psychosocial interventions; provision of care within a model that blends clinical and psychosocial support services; and, negotiation of family-inclusive practice. CONCLUSIONS: The Y-PARC service model shows promise with young people experiencing mental ill health, particularly in improving the range and availability of options across a spectrum of need.

Barriers and enablers to meaningful youth participation in mental health research: qualitative interviews with youth mental health researchers.

BACKGROUND: Involving young people in co-designing and conducting youth mental health research is essential to ensure research is relevant and responsive to the needs of young people. Despite this, many barriers exist to meaningful involvement. AIMS: To explore the experiences, barriers and enablers to partnering with young people for mental health research. METHODS: Semi-structured, qualitative interviews were conducted with 19 researchers employed at a youth mental health research institute in Australia. Thematic analysis was used to analyse these data. RESULTS: How researchers conceptualise youth participation was related to how confident and competent they felt engaging with young people. Attitudes and beliefs about the impact of youth participation on research quality were related to emotional factors, such as feelings of anxiety or excitement. Whether researchers engaged in youth participation was affected by resources, culture and the structures that their organisation had in place. CONCLUSION: Researchers generally want to engage young people in their work, but several factors can hinder this. By understanding the challenges facing researchers, and drawing on the factors that encourage and support those already engaging with young people, a framework to support genuine and meaningful youth participation in mental health research can be developed.

Supported decision-making from the perspectives of mental health service users, family members supporting them and mental health practitioners.

BACKGROUND: Supporting the decision-making of mental health service users fulfils professional, ethical and moral obligations of mental health practitioners. It may also aid personal recovery. Previous research on the effectiveness of supported decision-making interventions is limited. AIMS: The study aims to explore from several perspectives the barriers and facilitators to supported decision-making in an Australian context. Supported decision-making was considered in terms of interpersonal experiences and legal supported decision-making mechanisms. METHODS: In all, 90 narrative interviews about experiences of supported decision-making were conducted and analysed. Participants were mental health service users who reported diagnoses of schizophrenia, psychosis, bipolar disorder and severe depression; family members supporting them and mental health practitioners, including psychiatrists. The data were analysed thematically across all participants. RESULTS: Negative interpersonal experiences in the mental health care system undermined involvement in decision-making for people with psychiatric diagnoses and family carers. Mental health practitioners noted their own disempowerment in service systems as barriers to good supported decision-making practices. All groups noted the influence of prevailing attitudes towards mental health service users and the associated stigma and discrimination that exist in services and the broader community. They believed that legal supported decision-making mechanisms facilitate the participation of mental health service user and their family supporters in supported decision-making. CONCLUSIONS: Enabling supported decision-making in clinical practice and policy can be facilitated by (1) support for good communication skills and related attitudes and practices among mental health practitioners and removing barriers to their good practice in health and social services and (2) introducing legal supported decision-making mechanisms.

Supported Decision-Making: The Expectations Held by People With Experience of Mental Illness.

Supported decision-making (SDM) is a principle guiding mental health service provision, which aims to improve people's ability to make informed decisions about their care. Understanding diverse individual needs is vital to its success. Based on 29 narrative interviews with people diagnosed with mental illness in Australia, we examine how participants reflected on their own experiences of SDM. We find that participants' conceptualization of mental health expertise, their own experiences and sense of agency, and their varying needs for dependence and independence influenced their relationships with mental health practitioners. These factors in turn shaped their expectations about SDM. Four narrative positions emerged: the "Inward Expert," the "Outward Entrustor," the "Self-Aware Observer," and the "Social Integrator." These positionings influenced the type or style of support that participants expected and considered most useful. Our findings are relevant to developing effective approaches to SDM that take into account service users' needs and preferences.