Qualitative Analysis of Recommendations in 79 Inquiries after Homicide Committed by Persons with Mental Illness

‘Building a Safer NHS for Patients’ proposes significant changes to the reporting of adverse events in Britain’s healthcare system including the place of inquiries in the analysis of adverse events. Within mental health services, since 1994 an independent inquiry has been mandatory for all homicides committed by persons in contact with mental health services. The inquiry reviews the care the patient was receiving at the time of the incident, the suitability of that care with regard to the patients history, health and social care needs, and the extent to which the care corresponded with statutory obligations of the health service. A report is usually published following each inquiry including a set of recommendations based on the findings of the inquiry. The assumption is that these recommendations are intended to influence mental health policy and practice. However, many critics argue that inquiry reports and their recommendations have yet to substantially alter policy and practice

Listening to Voices: Understanding and Self-Management of Auditory Verbal Hallucinations in Young Adults

Aims Auditory Verbal Hallucinations (AVH) are a hallmark of psychosis, but affect many other clinical populations. Patients’ understanding and self-management of AVH may differ between diagnostic groups, change over time, and influence clinical outcomes. We aimed to explore patients’ understanding and self-management of AVH in a young adult clinical population. Method 35 participants reporting frequent AVH were purposively sampled from a youth mental health service, to capture experiences across psychosis and non-psychosis diagnoses. Diary and photo-elicitation methodologies were used – participants were asked to complete diaries documenting experiences of AVH, and to take photographs representing these experiences. In-depth, unstructured interviews were held, using participant-produced materials as a topic guide. Conventional content analysis was conducted, deriving results from the data in the form of themes. Result Three themes emerged: (1)Searching for answers, forming identities – voice-hearers sought to explain their experiences, resulting in the construction of identities for voices, and descriptions of relationships with them. These identities were drawn from participants’ life-stories (e.g., reflecting trauma), and belief-systems (e.g., reflecting supernatural beliefs, or mental illness). Some described this process as active / volitional. Participants described re-defining their own identities in relation to those constructed for AVH (e.g. as diseased, 'chosen', or persecuted), others considered AVH explicitly as aspects of, or changes in, their personality. (2)Coping strategies and goals – patients’ self-management strategies were diverse, reflecting the diverse negative experiences of AVH. Strategies were related to a smaller number of goals, e.g. distraction, soothing overwhelming emotions, 'reality-checking', and retaining agency. (3)Outlook – participants formed an overall outlook reflecting their self-efficacy in managing AVH. Resignation and hopelessness in connection with disabling AVH are contrasted with outlooks of “acceptance” or integration, which were described as positive, ideal, or mature. Conclusion Trans-diagnostic commonalities in understanding and self-management of AVH are highlighted - answer-seeking and identity-formation processes; a diversity of coping strategies and goals; and striving to accept the symptom. Descriptions of “voices-as-self”, and dysfunctional relationships with AVH, could represent specific features of voice-hearing in personality disorder, whereas certain supernatural/paranormal identities and explanations were clearly delusional. However, no aspect of identity-formation was completely unique to psychosis or non-psychosis diagnostic groups. The identity-formation process, coping strategies, and outlooks can be seen as a framework both for individual therapies and further research

Ticket to Talk: Supporting Conversation between Young People and People with Dementia through Digital Media

We explore the role of digital media in supporting intergenerational interactions between people with dementia and young people. Though meaningful social interaction is integral to quality of life in dementia, initiating conversation with a person with dementia can be challenging, especially for younger people who may lack knowledge of someone’s life history. This can be further compounded without a nuanced understanding of the nature of dementia, along with an unfamiliarity in leading and maintaining conversation. We designed a mobile application - Ticket to Talk - to support intergenerational interactions by encouraging young people to collect media relevant to individuals with dementia to use in conversations with people with dementia. We evaluated Ticket to Talk through trials with two families, a care home, and groups of older people. We highlight difficulties in using technologies such as this as a conversational tool, the value of digital media in supporting intergenerational interactions, and the potential to positively shape people with dementia’s agency in social settings

Aberrant salience network functional connectivity in auditory verbal hallucinations::a first episode psychosis sample

Auditory verbal hallucinations (AVH) often lead to distress and functional disability, and are frequently associated with psychotic illness. Previously both state and trait magnetic resonance imaging (MRI) studies of AVH have identified activity in brain regions involving auditory processing, language, memory and areas of default mode network (DMN) and salience network (SN). Current evidence is clouded by research mainly in participants on long-term medication, with chronic illness and by choice of seed regions made 'a priori'. Thus, the aim of this study was to elucidate the intrinsic functional connectivity in patients presenting with first episode psychosis (FEP). Resting state functional MRI data were available from 18 FEP patients, 9 of whom also experienced AVH of sufficient duration in the scanner and had symptom capture functional MRI (sc fMRI), together with 18 healthy controls. Symptom capture results were used to accurately identify specific brain regions active during AVH; including the superior temporal cortex, insula, precuneus, posterior cingulate and parahippocampal complex. Using these as seed regions, patients with FEP and AVH showed increased resting sb-FC between parts of the SN and the DMN and between the SN and the cerebellum, but reduced sb-FC between the claustrum and the insula, compared to healthy controls.It is possible that aberrant activity within the DMN and SN complex may be directly linked to impaired salience appraisal of internal activity and AVH generation. Furthermore, decreased intrinsic functional connectivity between the claustrum and the insula may lead to compensatory over activity in parts of the auditory network including areas involved in DMN, auditory processing, language and memory, potentially related to the complex and individual content of AVH when they occur

Major depressive disorder and schizophrenia are associated with a disturbed experience of temporal memory

Background Disturbances in ‘psychological time’ are frequently reported in major depressive disorder (MDD) and schizophrenia. If one accepts the suggestion that the experience of the dimensions of time, past-present-future, are not inseparable then a disturbance in episodic memory is implicated. Episodic memory allows us to make sense of the world and our place within it by constructing a temporal context and temporal flow between events. These temporal representations are disordered in schizophrenia, but whether this is reflected in MDD is not known. Temporal-order memory deficits can be explained by two hypotheses. The prefrontal-organisational hypothesis suggests that deficits result from a breakdown in processes involved in encoding, retrieval, monitoring and decision-making. Whereas the hippocampal-mnemonic theory suggests that item-encoding, and inter-item associative encoding contribute to temporal-order memory. Methods New learning, recency judgments and executive function were investigated in 14 MDD patients, 15 schizophrenia patients and 10 healthy volunteers (HVs). Results Relative to HVs, both MDD and schizophrenia made more temporal errors despite achieving 100% learning. Deficits in executive function and item-recognition were present in both psychiatric groups, but executive function correlated to temporal errors in MDD only, and item-recognition to new learning in schizophrenia only. Limitations MDD and schizophrenia patients were taking medication Conclusions Temporal-ordering deficits are evident in both MDD and schizophrenia, and whilst the disruption of organisational and mnemonic processes appears to be ubiquitous, preliminary evidence from the correlational analysis suggests prefrontal problems are implicated in MDD temporal-order deficits, whereas hippocampal are more associated to temporal-order memory deficits in schizophrenia

Standard setting: Comparison of two methods

BACKGROUND: The outcome of assessments is determined by the standard-setting method used. There is a wide range of standard – setting methods and the two used most extensively in undergraduate medical education in the UK are the norm-reference and the criterion-reference methods. The aims of the study were to compare these two standard-setting methods for a multiple-choice question examination and to estimate the test-retest and inter-rater reliability of the modified Angoff method. METHODS: The norm – reference method of standard -setting (mean minus 1 SD) was applied to the 'raw' scores of 78 4th-year medical students on a multiple-choice examination (MCQ). Two panels of raters also set the standard using the modified Angoff method for the same multiple-choice question paper on two occasions (6 months apart). We compared the pass/fail rates derived from the norm reference and the Angoff methods and also assessed the test-retest and inter-rater reliability of the modified Angoff method. RESULTS: The pass rate with the norm-reference method was 85% (66/78) and that by the Angoff method was 100% (78 out of 78). The percentage agreement between Angoff method and norm-reference was 78% (95% CI 69% – 87%). The modified Angoff method had an inter-rater reliability of 0.81 – 0.82 and a test-retest reliability of 0.59–0.74. CONCLUSION: There were significant differences in the outcomes of these two standard-setting methods, as shown by the difference in the proportion of candidates that passed and failed the assessment. The modified Angoff method was found to have good inter-rater reliability and moderate test-retest reliability

Pathways to mental healthcare in south-eastern Nigeria

In sub-Saharan Africa, traditional and faith healers provide competing services alongside biomedical professionals. This may be associated with delays in reaching specialised mental health services, and hence with longer duration of untreated illness. As first line care constitutes a crucial stage in accessing of psychiatric care, investigating pathways to mental healthcare can highlight help-seeking choices. This study explored the pathways to care for mental illness preferred by a non-clinical sample of the population in south-eastern Nigeria. Multistage sampling was used to select participants (N = 706) who completed questionnaires on help-seeking. Results showed a significant preference for biomedical (90.8%) compared to spiritual (57.8%) and traditional (33.2%) pathways. Higher education predicted preference for the biomedical model, while low education was associated with traditional and spiritual pathways. Protestants preferred the spiritual pathway more than did Catholics. The use of biomedical care is potentially undermined by poor mental health infrastructure, a lack of fit between the culture of biomedical care and the deep-seated cultural/religious worldviews of the people, stigma surrounding mental illness, and the likelihood of a social desirability bias in responses. A complementary model of care is proposed