Ethical decision making:advance directives and electroconvulsive therapy (ECT)

This thesis comprises a literature review, a research paper and a critical review of the research process. In the literature review, a meta-ethnography was conducted in order to identify and synthesise 17 studies that explored a person’s experience and understanding of advance directives in physical health care. Four themes emerged: ‘hope and fears for the family’; ‘the trust between the participant and the doctor’; ‘the communication of advance directives by health care staff’ and ‘hope and fears for the individual’s future. The findings are discussed in terms of culture and identity, affective forecasting and the notion of ‘conditional autonomy’. The empirical paper used a grounded theory informed methodology with ten participants who were all mental health professionals with experience of making a decision to give someone ECT or not. The ten participants were interviewed in order to develop a model that explained how this process occurred in clinical practice. The critical review discusses my own epistemological position in relation to the research process and how it influenced my choice of methodology. The limitations of the research will then be reviewed specifically focusing on the challenges of involving expert by experience consultants (EbE) and recruiting service users and family to the research. The paper is concluded by linking the two research papers together by discussing the role of advance directives in ECT

Psychological Distress and Socioeconomic Status. A Consideration of Associated Factors

Section one reports a quantitative systematic literature review which explores the acceptability of mental health services for people of low socioeconomic status. Four databases were searched (PsycInfo, CINAHL complete, MEDLINE and Academic Search Ultimate) and ten studies met the inclusion criteria. A narrative synthesis approach was implemented to systematically explore the findings of the papers. The psychological factors considered in relation to acceptability were: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, self-efficacy and cultural competence. Methodological quality was assessed using the Joanne Briggs Institute Critical Appraisal Checklist for Analytical Cross Sectional Studies. Concerns were noted regarding the measures of predictor and outcome variables. Strengths were found in the statistical analysis of confounders. Section two reports an empirical study investigating food insecurity in the United Kingdom. This research aimed to understand 1) the relationship between food insecurity and psychological distress and 2) whether shame moderates the relationship between these variables. Participants were aged 18+ and self-identified as food insecure within the previous six months. A cross-sectional survey was conducted online and via paper copies, consisting of measures of food insecurity, psychological distress and shame. The study findings show that food insecurity and shame account for 74% of the variance in psychological distress in people who report food insecurity. No moderation was found suggesting the relationship between food insecurity and psychological distress is not moderated by shame. However, a significant interaction may not have been found, as the study may have been underpowered. The findings of this research have implications for those working in both mental health services and food aid organisations and these are discussed. Section three contains a critical appraisal of issues relating to research into deprivation, including discussion of the sociopolitical context in which this research took place. Suggestions for future research are given

What is the process by which a decision to administer Electroconvulsive Therapy (ECT) or not is made?:A grounded theory informed study of the multi-disciplinary professionals involved

Purpose: To develop a grounded theory informed model explaining the decision-making process professionals in multi-disciplinary teams go through in deciding whether to administer Electroconvulsive therapy (ECT) or not. Methods: A grounded theory informed methodology was used to analyse the data offered by ten participants who had all been involved in the process of deciding if someone has ECT or not. Results: The core categories, described as ‘layers’ in this research, ‘personal and professional identity’; ‘subjective vs objective’; ‘Guidelines or Clinical Instinct?’; ‘Someone has to take Responsibility’ and ‘the decision in action’ were constructed from the data. Conclusions: The study describes a useful insight into the layers of the decision-making process that could be further considered in clinical settings. The model highlights the decision to give ECT includes many different layers including professional identity, how a person understands the evidence base, past experiences, and the amount of power they have in the process. The consultant psychiatrist and the patient were seen as holding most power in the process depending on whether the Mental Capacity Act (2005) or Mental Health Act (2007) was being followed. Patients were seen to experience a very different decision-making process dependant on the personal views of the professionals in relation to ECT

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review

Introduction: Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods: A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT—Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results: We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion: Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration: [Prospero], identifier [CRD42021284959]

Martian dust storm impact on atmospheric H₂O and D/H observed by ExoMars Trace Gas Orbiter

Global dust storms on Mars are rare but can affect the Martian atmosphere for several months. They can cause changes in atmospheric dynamics and inflation of the atmosphere, primarily owing to solar heating of the dust. In turn, changes in atmospheric dynamics can affect the distribution of atmospheric water vapour, with potential implications for the atmospheric photochemistry and climate on Mars. Recent observations of the water vapour abundance in the Martian atmosphere during dust storm conditions revealed a high-altitude increase in atmospheric water vapour that was more pronounced at high northern latitudes, as well as a decrease in the water column at low latitudes. Here we present concurrent, high-resolution measurements of dust, water and semiheavy water (HDO) at the onset of a global dust storm, obtained by the NOMAD and ACS instruments onboard the ExoMars Trace Gas Orbiter. We report the vertical distribution of the HDO/H O ratio (D/H) from the planetary boundary layer up to an altitude of 80 kilometres. Our findings suggest that before the onset of the dust storm, HDO abundances were reduced to levels below detectability at altitudes above 40 kilometres. This decrease in HDO coincided with the presence of water-ice clouds. During the storm, an increase in the abundance of H2O and HDO was observed at altitudes between 40 and 80 kilometres. We propose that these increased abundances may be the result of warmer temperatures during the dust storm causing stronger atmospheric circulation and preventing ice cloud formation, which may confine water vapour to lower altitudes through gravitational fall and subsequent sublimation of ice crystals. The observed changes in H2O and HDO abundance occurred within a few days during the development of the dust storm, suggesting a fast impact of dust storms on the Martian atmosphere

No detection of methane on Mars from early ExoMars Trace Gas Orbiter observations

The detection of methane on Mars has been interpreted as indicating that geochemical or biotic activities could persist on Mars today. A number of different measurements of methane show evidence of transient, locally elevated methane concentrations and seasonal variations in background methane concentrations. These measurements, however, are difficult to reconcile with our current understanding of the chemistry and physics of the Martian atmosphere, which-given methane's lifetime of several centuries-predicts an even, well mixed distribution of methane. Here we report highly sensitive measurements of the atmosphere of Mars in an attempt to detect methane, using the ACS and NOMAD instruments onboard the ESA-Roscosmos ExoMars Trace Gas Orbiter from April to August 2018. We did not detect any methane over a range of latitudes in both hemispheres, obtaining an upper limit for methane of about 0.05 parts per billion by volume, which is 10 to 100 times lower than previously reported positive detections. We suggest that reconciliation between the present findings and the background methane concentrations found in the Gale crater would require an unknown process that can rapidly remove or sequester methane from the lower atmosphere before it spreads globally

Refugees' and asylum seekers' experiences of individual psychological therapy:A qualitative meta‐synthesis

Purpose: The current review aimed to synthesise qualitative literature exploring adult refugees' and asylum seekers' experiences of individual psychological therapy. Methods: A comprehensive systematic search of the following databases led to the identification of eight studies for inclusion in this review: PsycINFO, PsycARTICLES, MEDLINE, EMBASE, CINAHL and Academic Search Ultimate. All selected studies used qualitative methodology to explore refugees' and asylum seekers' experiences of individual psychological therapy. Studies were appraised using an adapted version of the Critical Appraisal Skills Programme (CASP) Tool. The data from these selected studies were then synthesised using a meta‐ethnographic approach. Results: The synthesis of selected studies resulted in the development of five themes; (i) the importance of recognition and validation within therapy, (ii) building a human connection within the therapeutic relationship and the importance of cultural competency, (iii) revisiting trauma, managing difficult emotions from therapy and regaining hope, (iv) the value of practical interventions, (v) ‘one should not wake up the djinns (demons)’—cultural stigma and accessing therapy. These themes illustrated the complexities of working therapeutically with asylum seekers and refugees and the vital role of building trust and safety within the therapeutic relationship prior to engagement in therapeutic work. The results also highlighted varied responses to engaging in trauma work ranging from participants finding the experience transformative to others finding it unhelpful, some participants preferred more practical interventions. Participants' cultural backgrounds and pre‐conceptions around therapy impacted on engagement and the therapist's cultural competency was a significant factor in therapeutic engagement. Conclusions: Working therapeutically with asylum seekers and refugees involves a number of factors for consideration. Forced migrants' socio‐political context was seen as central to their experiences of distress and recognition of these factors was imperative for positive therapeutic engagement. This review highlights a number of clinical implications to guide practitioners working therapeutically with this community