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Objective: Recent literature suggests that female physicians provide higher quality of care compared to their male counterparts across a variety of physical medical conditions. We examine whether a similar phenomenon is observed for psychiatry residents treating hospitalised psychiatric patients., Methods: We analysed 300 hospitalised patient records from Shalvata Mental Healthcare Centre (Hod Hasharon, Israel). Resident-patient sex matchings were compared., Results: No significant differences were observed in terms of residents' age and patients' age, medical condition and hospitalisation history. Male and female patients treated by female residents presented shorter hospitalisations (58 and 54 days compared to 67 and 66 days, respectively, p < . 05), longer time to next hospitalisation (269 and 179 days compared to 179 and 123 days, respectively, p < . 01), lower 30-day readmission rate (37% and 35% compared to 10% and 19%, respectively, p < . 05), higher levels of family involvement during hospitalisation (2.6 and 2.7 points compared to 2.1 and 1.9 points, respectively, p < . 01) and higher chances of obtaining rehabilitation services (39% and 34% vs. 23% and 17%, respectively, p < . 05)., Conclusions: Hospitalised patients treated by female psychiatry residents are associated with better hospitalisation outcomes compared to those cared for by male residents. KEY POINTSBoth male and female patients treated by female residents presented better hospitalisation outcomes.These hospitalisation outcomes include shorter hospitalisation periods, longer time to next hospitalisation, lower 30-day remission rate, significantly higher levels of family involvement and higher chances of obtaining rehabilitation services.Further work is needed in order to investigate the sources and reasons for the identified differences.

Abstract Background Health institutions advocate for psychosocial and recovery-oriented interventions alongside pharmacological treatment for severe mental illness. Participatory arts interventions appear promising in promoting personal recovery by fostering connectedness, hope, renegotiation of identity, meaning-making, and empowerment. Despite encouraging findings, however, the evidence base remains thin. Further, results from cognitive literature studies suggest possible impact on parameters of clinical recovery, but this has not been studied in clinical contexts. We developed REWRITALIZE, a structured, recovery-oriented, fifteen-session creative writing group intervention led by a professional author alongside a mental health professional. Participants engage with literary forms, write on them, share their texts, and partake in reflective discussions within a supportive, non-stigmatising environment, designed to promote self-expression, playful experimentation, agency, recognition, participatory meaning-making, renegotiation of identity and social engagement. The aim of this project is to evaluate REWRITALIZE for persons with severe mental illness through a randomised controlled trial (RCT) focusing on personal recovery outcomes. Additionally, an embedded pilot RCT will explore additional outcomes i.e., clinical recovery for a subgroup with schizophrenia spectrum disorders. Methods The RCT is an investigator-initiated, randomised, two-arm, assessor-blinded, multi-center, waiting-list superiority trial involving 300 participants (age > 18) from six psychiatric centers in regions Capital and Zealand in Denmark, randomised to receive either the creative writing intervention combined with standard treatment or standard treatment alone. Assessments will be conducted before and after the intervention and at six months post intervention. The primary outcome is personal recovery at the end of intervention measured with the questionnaire of the process of recovery. Secondary outcomes include other measures of personal recovery, self-efficacy, mentalising, and quality of life. The pilot RCT, integrated within the RCT, will focus on 70 of the participants aged 18–35 with schizophrenia spectrum disorders, evaluating exploratory measures related to perspective-taking, social cognition, cognitive function, psychosocial functioning, and symptom pressure. Discussion This is the first RCT for creative writing groups. It assesses whether REWRITALIZE, as adjunct to standard mental healthcare, is more effective for personal recovery than standard care. If successful, it would provide evidence for the efficacy of REWRITALIZE, potentially enabling its implementation across mental health centers in Denmark. Trial registration Privacy (data protection agency): p-2023–14655. Danish National Center for Ethics: 2313949. Clinicaltrials.gov: NCT06251908. Registration date 02.02.2024.

Abstract Background Recovery from severe mental illness, including psychosis has been described as a personal and unique process, but it rarely is a journey undertaken without profound influences of significant others (family, mental health professionals). Diverging perspectives between persons with severe mental illness, family and professionals are frequent during the recovery process, notably in psychotic disorders. We aimed to explore processes of collaboration during recovery, to inform recovery supporting practices. Methods Current qualitative study had a participatory design and was set within long-term mental healthcare for severe mental illness. We conducted semi-structured interviews and focus groups with persons with severe mental illness (most had a history of psychosis), family and professionals on their mutual contact during recovery. Using reflexive thematic analysis, we developed themes representing processes of collaboration during recovery. Results We described roles persons with severe mental illness, family and professionals attribute to each other in mutually influential terms of unconditional and meaningful contact (which takes time to establish) and problem-oriented aspects. Secondly, experienced differences over problem definition, “needing help” and consequently over the role parties attribute to one another, may result in negative interactions, in the area of having expectations; (not) informing; (not) having agency to change; experiencing (dis)agreement or struggle. Conclusions unconditional, meaningful contact and knowing each other’s perspective are important to fruitful interaction in a triad when perspectives on mental health problems diverge. Relationally centered and process oriented care with continuity of family and professionals involved are needed to advance recovery in severe mental illness, especially psychosis.

Objective: Weight gain can harm health and be socially stigmatizing. We sought to determine whether weight gain during the inpatient stay, as collateral damage related to lockdown, was more in patients admitted during the lockdown in the first pandemic year than in those admitted during the same period in the immediately preceding year. To our knowledge, this has not been previously investigated. Methods: We extracted from medical record weight data during two similar 4-month periods (April–July) in 2019 and 2020. We examined the impact of the ward restrictions during the pandemic lockdown on weight gain using multivariable regression analysis, adjusting for potential confounding variables selected a priori: age, sex, baseline weight, metabolic syndrome or antipsychotic load, and duration of inpatient stay. Results: There were 59 patients, almost all with schizophrenia spectrum disorders. Patients admitted in 2019 (n = 27) were significantly more likely to consume alcohol or use illicit substances, but otherwise did not differ much from those admitted in 2020 (n = 32). Weight gain during inpatient stay was not statistically significant for 2019 (+1.85 kg; P = 0.22), 2020 (+0.74 kg; P = 0.26), or for the 2 years combined (+1.25 kg; P = 0.10). Finally, weight gain during inpatient stay did not differ between 2019 and 2020 (P = 0.83). In the regression analysis, the year of admission was not significantly associated with change in weight during inpatient stay (beta, −0.11; P = 0.43). Conclusions: Our findings validate our ward strategies to reduce the risk of weight gain during lockdown in inpatients with severe mental illness.

Abstract Background People with severe mental illness (SMI) face not only impaired mental health, but also a greater risk of physical comorbidities and a shorter life expectancy compared to the general population. A poor lifestyle plays a substantial role in this disparity. Combined Lifestyle Interventions targeting multiple lifestyle behaviors can improve mental and physical health, and quality of life. However, there is currently no appropriate structural support for people with SMI in outpatient care in the Netherlands. The Combined Lifestyle Intervention for Outpatients with SMI (GOAL!) is developed to address this gap. This study examines the (cost-)effectiveness and implementation of GOAL!. Methods In a type 1 hybrid quasi-experimental study with a mixed-method matched design, GOAL! participants (N = 50) are compared to people receiving care as usual (N = 50). The GOAL! program includes group and individual sessions, given by allied health professionals, over a period of two years. The first year starts with a 3-month intensive course on physical activity and nutrition, followed by 9 months of aftercare covering various lifestyle topics tailored to the group’s needs. There is close collaboration with local stakeholders to facilitate transfer to the community setting. The second year focuses on maintaining established activities in one’s daily living environment. Our primary outcome will be the change in physical activity, comparing GOAL! participants to those receiving care as usual. Secondary outcomes are changes in other lifestyle behaviors, physical health, mental well-being, and healthcare and societal costs. Additionally, achieving lifestyle-related goals, adverse effects, and barriers and facilitators to implementation are examined. Measurements are obtained at start (T0), and after 3 (T1), 12 (T2) and 24 months (T3). Discussion This study investigates the effects of GOAL! on lifestyle behaviors, health outcomes, implementation factors and cost-effectiveness after two years, aiming to offer valuable insights into the effectiveness and implementation outcomes of lifestyle interventions for outpatients with SMI. Trial registration : ClinicalTrials.gov (Identifier: NCT05600205). Prospectively registered on October 26, 2022.

This perspective article applies public health principles to improve the physical health of selected populations with mental disorders. Two preventable adverse outcomes, poorer physical health and premature mortality, are described across mental disorders. Evidence of the lifetime effects of adverse childhood experiences and inequalities is presented: these are the 'causes of the causes'. Seven drivers of physical disorders are illustrated that drive preventable deaths and as doctors, psychiatrists must lead from the front to reverse rising mortality. Evidence supports universal and selective interventions and even the most difficult challenges such as weight gain and opioid misuse are an opportunity for psychiatry to engage with individual patients and their organisations, public health colleagues, health systems and beyond. Interventions complement and do not replace existing clinical practices that reduce self-harm and prevent suicide. Mental health teams already do most of the work in this arena, and the case is made to refocus on physical health with task sharing. The top 10 recommendations within a personalised medicine framework are listed in this paper as a starting point.

Background Severe mental illness (SMI), which includes schizophrenia, schizoaffective disorder and bipolar disorder, has profound health impacts, even in the elderly. Aims To evaluate relative risk of hospital admission and length of hospital stay for physical illness in elders with SMI. Method To construct a population-based retrospective cohort observed from April 2007 to March 2016, data from a case registry with full but de-identified electronic health records were retrieved for patients of the South London and Maudsley NHS Foundation Trust, the single secondary mental healthcare service provider in south-east London. We compared participants with SMI aged >60 years old with the general population of the same age and residing in the same areas through data linkage by age-, sex- and fiscal-year-standardised admission ratios (SARs) for primary diagnoses at hospital discharge. Furthermore, we compared the duration of hospital stay with an age-, sex- and cause-of-admission-matched random group by linear regression for major causes of admission. Results In total, records for 4175 older people with SMI were obtained, relating to 10 342 admission episodes, showing an overall SAR for all physical illnesses of 5.15 (95% CI: 5.05, 5.25). Among the top causes of admission, SARs ranged from 3.87 for circulatory system disorders (ICD-10 codes: I00–I99) to 6.99 for genitourinary system or urinary conditions (N00–N39). Specifically, the diagnostic group of ‘symptoms, signs and findings, not elsewhere classified’ (R00–R99) had an elevated SAR of 6.56 (95% CI: 6.22, 6.90). Elders with SMI also had significantly longer hospital stays than their counterparts in the general population, especially for digestive system illnesses (K00–K93), after adjusting for confounding. Conclusions Poorer overall physical health and specific patterns were identified in elders with SMI.

Background: Electroconvulsive therapy (ECT) has been an effective treatment option available for elderly patients with severe mental illness; however, there are concerns related to its tolerability. Unilateral ECT has fewer cognitive adverse effects compared to bilateral ECT while efficacy with bilateral ECT is better. Aim: To evaluate the tolerability and efficacy of Bi-temporal ECT in elderly patients (>60 years) with severe mental illness in a general hospital set-up. Methodology: The study was a prospective, observational study conducted in SDM College of Medical Sciences and Hospital, Dharwad with a sample size of 15 elderly patients aged above 60 years with severe mental illness. Participants were screened for psychiatric symptoms with Mini-International Neuropsychiatric Interview and assessed for severity of symptoms with Hamilton Depression Rating Scale, Young Mania Rating Scale, and Positive and Negative Syndrome Scale. Cognitive functioning was assessed by Hindi Mental Status Examination Scale and effectiveness was assessed using global functioning by Global Assessment of Functioning (GAF) Scale. Assessment was done before giving ECT and 4 weeks at follow-up. The study period was from January 2019 to December 2019. Results and Conclusions: The median age of the elderly was 61 years. Majority (66.7%) were diagnosed with mood disorder and 33.3% of the patients were diagnosed with paranoid schizophrenia. Around 47% had comorbid hypertension and 33.3% had diabetes mellitus. All the patients in the study sample received thrice weekly bi-temporal ECT in the range of 2–8 with median of 5. Significant reduction in symptomatology was observed, on comparing the scores before and after ECT with improvement in overall functioning assessed by GAF Scale. There was no decline in cognitive functioning test, although there was an improvement in the Hindi version of mini mental status examination scores at 4 weeks after discharge. By the above observations, we concluded that the use of bi-temporal ECT in elderly patients with severe mental illness was found to be safe and effective in treating.

Abstract Background People with severe mental illness (SMI) such as schizophrenia and bipolar disorder are at a substantially higher risk of premature death in that they die between 10 and 20 years earlier than the general population. Cardiovascular disease (CVD) and diabetes are the main potentially avoidable contributors to early death. Research that explores the experiences of people with SMI highlights their struggles in engaging with health professionals and accessing effective and timely interventions for physical health conditions. A consequence of such struggles to navigate and access physical healthcare results in many people with SMI relying heavily on support provided by informal carers (e.g., family members, close friends). Despite this, the experiences of informal carers, and the roles they undertake in relation to supporting the physical health and psychotropic medication use of people with SMI, remains under-researched. Aims To explore the impacts of providing care for physical health in severe mental illness on informal carers. Method Thematic analysis of semi-structured interviews with eight informal carers of people with SMI in United Kingdom (UK) national health services. Results Informal carers played an active part in the management of the patient’s conditions and shared their illness experience. Involvement of informal carers was both emotional and practical and informal carers’ own lives were affected in ways that were sometimes deeply profound. Informal carers were involved in both ‘looking after’ the patient from the perspective of doing practical tasks such as collecting dispensed medication from a community pharmacy (caring for) and managing feelings and emotions (caring about). Conclusions Providing care for the physical health of someone with SMI can be understood as having two dimensions - ‘caring for’ and ‘caring about’. The findings suggest a bidirectional relationship between these two dimensions, and both have a cost for the informal carer. With appropriate support informal carers could be more actively involved at all stages of care without increasing their burden. This should be with an awareness that carers may minimise the information they share about their own needs and impacts of their role to spare the person they care and themselves any distress.

Abstract Introduction Victimisation of persons with severe mental illness is recognised as an urgent global concern, with literature pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population. Yet, for low income countries, there is a huge gap in the literature on the risk, character and victims’ in-depth experiences of victimisation of persons with severe mental illness. We explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, and discuss their implications for care of the mentally ill. Methods A pluralistic qualitative study was undertaken to explore victimisation among patients with severe mental illness. Patients who had suffered victimisation were purposively sampled from Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital, following confirmation of symptom remission. In-depth interviews were held with 18 participants, comprising 13 females and 5 males from low to moderate socioeconomic status. Interpretative phenomenological analysis and thematic content analysis were conducted. Results Victimisation was exhibited in three main forms: (a) psychological, expressed in attitudes towards mentally ill family members as valueless and dispensable, and stigmatisation, (b) physical, as manifested in beatings, indoor confinement and tethering mostly by family members and (c) sexual victimisation, particularly rape. Also observed were victim’s various responses that pointed to the negative impact of victimisation, including a heightened risk of suicide, social withdrawal, a sense of hatefulness and a predisposition to more victimisation. Conclusion The family environment plays a predominant role in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts such as Uganda. We propose a holistic framework for mental health interventions, incorporating biomedical but notably also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Abstract Background Severe mental illness (SMI) imposes a substantial worldwide burden of disability, highlighting the need for comprehensive and adaptable mental health services. This study aims to assess the efficacy and cost-effectiveness of community-based mental health services (CBMHS) in reducing relapse and rehospitalization rates among individuals with SMI in Iran. Method A systematic review and meta-analysis were conducted. Medline, EMBASE, ISI, SCOPUS, and ProQuest were searched until December 2022. We focused on randomized controlled trials, quasi-experimental studies, or economic studies related to individuals with SMI. Out of 127 articles, 17 were selected for a full-text review. The primary outcomes were the severity of psychopathology, rehospitalization rates, and the mental health of caregivers. We also examined community-based interventions and their impact on various outcomes. Data extraction and risk of bias assessment were performed, and critical appraisal was conducted using JBI checklists. Meta-analysis was carried out using STATA software. (PROSPERO registration. CRD42022332660). Result Rehospitalization rates among patients who received CBMHS were significantly lower, with an odds ratio of 2.14 (95% CI: 1.44 to 3.19), indicating a 2.14 times lower likelihood than those who received treatment as usual. A reduction in psychopathology accompanied this, SMD: -0.31, 95% CI: -0.49 to -0.13, I2 = 40.23%). Moreover, there was a notable improvement in social skills (SMD: -0.7, 95% CI: -0.98 to -0.44, I2 = 0.00%). The burden on caregivers also decreased (SMD: -0.55, 95% CI: -0.99 to -0.1, I2 = 63.2). The Incremental Cost-Effectiveness Ratio (ICER) for QUALY was acceptable, albeit with a wide range of 613 to 8400 Dollars. Conclusion CBMHS has demonstrated effectiveness and efficiency in Iran as a developing country. Additionally, it shows promise in mitigating the shortage of acute psychiatry beds. Using multiple data collection tools poses a limitation regarding data consolidation and conducting a meta-analysis.

Abstract Background In January 2017, the Norwegian government mandated the establishment of an inpatient unit for “medication-free treatment” for patients with severe mental illness at the University Hospital of North Norway in Tromsø. This study aims to explore the employees’ experiences with this unit. Method Focus group interviews were conducted October 2021 – February 2022. For analysis, the participants were divided into three groups; S (staff working at the medication-free unit), M (people involved in management at the unit) and T (therapists working elsewhere in the hospital). The analysis followed the Systematic Text Condensation and interviews were recorded, transcribed and analysed using NVivo software. Results Health professionals described their experiences with medication-free treatment through five main concepts: 1) Employees’ motivation; 2) Frames; 3) Network; 4) Relations; and 5) Patients’ motivation. Staff and management expressed strong motivation for an alternative to “treatment as usual,” focusing more on recovery and relationships than on the absence of medication. Therapists from other hospital areas highlighted resource allocation concerns and expressed a desire to learn from the unit. Challenges were acknowledged by all groups. Conclusion The term “medication-free treatment’’ might be misleadning. While patiens at the unit can use medications, there is a strong emphasis on patient autonomy and the option to taper off medication and live a life without them. The study adds valuable knowledge about the the experiences of employees working at a medication-free unit, and provides insights into the complexity of treating severe mental illness, both with and without medication. It highlights the importance of sufficient time, stability and resources to focus on each patient’s strengths and challenges. All employees agree that tailored measures in long-term treatment and a clear focus on recovery should be integral, even without an emphasis on “medication-free treatment”.

Background and Aim: Globally, very few patients with mental illness go to health care facilities to receive psychiatry treatment. This study aims to identify pathways used by patients with severe mental disorders who seek mental health care services in the psychiatry unit of AIIMS, New Delhi., Materials and Methods: It is a retrospective cross-sectional study with convenience sampling technique was used, and data were collected from 123 caregivers of patients with severe mental illnesses using standardized tools like MINI, BPRS, YMRS and WHO Encounter pathway., Results: The findings revealed that 41.5% of the patients made their first contact with the faith healers, 27.6% with AYUSH medical practitioners, 14.6% with psychiatrists and 12.2% with allopathic medical practitioners. About 26% of the patients reported hallucinations as the first symptom for seeking help. In the majority of cases (96.7%), the patient's relatives made the decision for the patient to seek treatment the first time to manage the symptoms. The psychotic symptoms (65.1%) helped the patient's relatives to take the decision for first seek. The mean delay for seeking treatment from psychiatrists was 13.31 ± 10.6 (months)., Conclusion: This study showed that a higher proportion of patients received treatment from the faith healer at the first seek, whereas only a few patients approached psychiatrist directly. Hence, there is an immense need to create awareness regarding mental illness and treatment options available.

BackgroundSevere mental illness results in an enormous social and economic burden on affected individuals, their families, and communities, especially in developing countries, such as Ethiopia.ObjectiveThe aim of this study was to assess the level of depression among caregivers of patients with severe mental illness in Debre Tabor Town, Northwest Ethiopia in 2023.MethodsThis institution-based explanatory mixed study was conducted at Debre Tabor Compressive Specialized Hospitals between September 30 to October 30, 2023. A systematic random sampling technique was used to select 260 study participants, and a public health questionnaire was used to assess depression. Epicollect5 was used to collect data, which were then exported to the SPSS-25 for analysis. Variables with a p-value

Introduction: The reason why some people with severe mental illness (SMI) maintain positive self-identity, while some are affected by the stigmatized environment is unclear. Aims: To describe the status of individual stigma and explore the relationship between self-stigma, stigma resistance and related variables in people with SMI. Methods: A cross-sectional study was conducted from April 2021 to March 2022. The Chinese version of Internalized Stigma of Mental Illness Scale and Stigma Resistance Scale were used to assess individual stigma. Perceived public stigma, psychological capital, stigma stress appraisal and coping orientations were also measured by scales. Data was provided by 422 patients with schizophrenia or bipolar disorder, from one psychiatric hospital and four community healthcare centers in China. A structural equation model was applied for analysis. Results: The total mean scores of self-stigma and stigma resistance were (2.06 ± 0.65), and (3.95 ± 0.84). Perceived public stigma was the primary condition for constructing individual stigma, which indirectly affected self-stigma (β = 0.268) and stigma resistance (β = −0.145). Stigma stress appraisal mediated the transformation of public stigma into individual, which had direct and indirect effects on self-stigma (β = 0.417, 0.166), and an indirect effect on stigma resistance (β = −0.374). Secrecy positively affected self-stigma (β = 0.117), while positive coping positively affected stigma resistance (β = 0.380). Psychological capital significantly directly impacted individual stigma. Conclusions: Findings highlighted how public stigma determines the degree to which patients with SMI deal with stigma stress appraisal, and how this influences individuals. Anti-stigma programs and interventions to improve individuals' psychological capital and coping capabilities should be emphasized.

IntroductionOccupational therapy (OT), a vital part of psychiatric rehabilitation, encourages participation in social activities, which is critical for the recovery of people with severe mental illnesses (SMI). However, the effects of OT on the subsequent social activities of patients with SMI have not been fully clarified. We aimed to identify the factors that encourage post-discharge social activity participation among patients with SMI who received OT.MethodPatients who underwent OT at the Kyorin University Hospital between April 2016 and March 2020 were retrospectively examined for baseline data during hospitalization and social activity status 1 year after discharge. Occupational support, group adaptation, artistic activities, and exercise programs were considered. Activities requiring social interaction were defined as social activities, including employment, schooling, sheltered work, and volunteer work. Multiple logistic regression analyses using demographic and medical data, prehospitalization social activity status, and OT participation rates as independent variables were used to examine the factors encouraging social activity participation after discharge. Decision tree analysis was conducted to identify patients who specifically needed to increase OT participation.ResultsOf 524 eligible patients, 247 were included in the study. The number of patients who were socially active at admission and after discharge was 116 and 188, respectively. Multiple logistic regression analyses revealed that the following factors were likely to encourage social activity participation after discharge: higher rates of OT participation to facilitate group adaptation (OR = 1.015, 95% CI 1.003–1.027), being socially active at admission (OR = 4.557, 95% CI 2.155–9.637), and no marital history (OR = 0.293, 95% CI 0.130–0.661). Decision tree analysis showed that for patients who were socially inactive at admission and had a history of marriage, increasing OT participation to 52.6% or higher may ensure social activity participation after discharge.ConclusionsThis study identified patients whose social participation after discharge could be boosted by OT that facilitates group adaptation. Our findings would facilitate the development of individualized add-on rehabilitation based on the effects of real-world OT practices.

Background and Aims: There is limited research on the impact of COVID-19 pandemic on caregivers of patients with severe mental illness (SMI) during its late phase when sufficient and widespread knowledge about management and preventive aspects existed. We aimed to assess the impact of COVID-19 pandemic on caregivers of patients with SMI during Omicron wave. Methodology: We assessed 100 caregivers of patients with preexisting SMI diagnosed on the Diagnostic and Statistical Manual of Mental Disorders-5, 50 each of schizophrenia and related psychotic disorders (SCZ) and bipolar disorder (BD) from December 14, 2021, to February 9, 2022. We assessed symptoms of depression, anxiety, stress, and family burden in caregivers and their coping strategies by the Depression, Anxiety, and Stress Scale-21 Hindi version, Family Burden Interview Schedule (FBIS), and Brief-Coping Orientation to Problem Experienced, respectively. Results: Caregivers of SMI experienced symptoms of depression (51%), anxiety (72%), and stress (13%), with significantly more symptoms of depression (P = 0.002) and anxiety (P = 0.025) in caregivers of SCZ. High caregiver burden (score: 25.76, > half of the total score on FBIS) was found with no significant difference in the two groups. Caregivers of SCZ used a greater number of emotion-focused coping strategies, whereas those with BD used more problem-focused coping, but the difference was not significant. A significant association was seen between coping strategies of substance use and depressed symptoms (P = 0.003), substance use and anxiety symptoms (P = 0.007); anxiety symptoms with denial (P = 0.001) anxiety symptoms and venting (P = 0.008) in caregivers of BD. Conclusion: Caregivers of patients with preexisting SMI experienced depression, anxiety, and high family burden during Omicron wave. They used both emotion- and problem-focused coping strategies.

BackgroundSevere mental illness has negative consequences not only for the person suffering from it but also for their caregiver’s quality of life and the community in which they reside. These impacts could be particularly visible in low- and middle-income countries, where the treatment gap for mental illnesses is particularly high. There is a dearth of evidence in Ethiopia.ObjectiveThis study aims to assess the quality of life and its associated factors among caregivers of patients with severe mental illness at Felege Hiwot and Tibebe Ghion Compressive Specialized Hospital, Bahir Dar, Northwest Ethiopia, in 2022.MethodsAn institution-based cross-sectional study design was conducted at Felege Hiwot and Tibebe Ghion Compressive Specialized Hospitals from 13 June to 13 July 2022. A systematic random sample technique was utilized to select 469 study participants. The World Health Organization quality of life-BREF questionnaire was utilized to assess quality of life, and perceived stigma was measured through a family interview schedule questionnaire. The data were gathered using the epicollect5 software with a face-to-face interview method and then exported to SPSS-25. Simple and multiple linear regression analyses were conducted to identify associated factors of quality of life for variables that are statistically significant (p-value< 0.05) with B-coefficients and a 95% CI. Descriptive statistics were used to describe the outcome and predictor variables.ResultsA total of 456 respondents participated, with a response rate of 97.2%. The result showed that the mean quality-of-life score of caregivers of patients with severe mental illness for each domain (mean ± standard deviations) was between 46.5 ± 18.7 and 51.2 ± 19.9, with the worst score of zero in the environmental domain and 94 in the social domain. In multiple regression, living in a rural area (B = −5.2; 95% CI, −8.9, −1.8), being illiterate (B = −7.2; 95% CI, −10.6, −3.7), having chronic medical illness (B = −5.2; 95% CI, −8.6, −1.7), having probable cases of anxiety (B = −6.9, 95% CI, −10.5, −13.3), having probable cases of depression (B = −4.9; 95% CI, −8.2, −1.7), and the presence of perceived stigma (B = −7.9; 95% CI, −11.2, −4.77) were significantly associated with the overall quality of life. This analysis suggests that the identified factors can predict over 40% of the variability in overall quality of life scores for caregivers.ConclusionThe quality of life of caregivers of patients with severe mental illness was found to be low. Living in a rural area, being illiterate, having chronic medical illnesses, having probable cases of anxiety and depression, and being stigmatized were negatively associated with the overall quality of life. The findings indicate the necessity for health professionals, the government, and other concerned bodies to pay more attention to caregivers’ quality of life.

Background: Affordability, lack of public mental healthcare facilities, inadequate insurance coverage, and stigma and discrimination are barriers to mental healthcare utilization in India. There is limited research on these barriers and the factors influencing the use of mental health services. Aim: To explore the barriers to seeking mental healthcare for individuals with severe mental illness and their caregivers in a modified assertive community treatment program. Methods: In a qualitative study using a descriptive thematic analysis, we conducted in-depth interviews with 19 adults, including seven individuals with severe mental illness and twelve caregivers. All the participants had been in the modified assertive community treatment program for at least two years. Using thematic analysis, we identified and grouped codes into subthemes and then clustered into themes. Results: Three major themes on barriers to seeking mental health services emerged: service-related factors, societal-related factors, and illness-related factors. Service-related factors included affordability, accessibility and geographical disparity, and noncoverage under insurance schemes. Societal-related factors included social stigma and discrimination, lack of mental health service knowledge and seeking other forms of treatment, and poor social support. Illness-related factors included poor insight into the illness and no relief from the symptoms despite medication. Conclusions: Barriers to seeking mental healthcare can be categorized as service-related, societal-related, and illness-related. Identifying these factors will improve mental health service delivery.

Abstract Background Most individuals with severe mental illness (SMI) strongly prefer independent living over living in an institution. Independent Supported Housing (ISH) provides housing rehabilitation for persons with SMI in their accommodations. However, most individuals who need housing rehabilitation live in institutional housing settings (housing rehabilitation as usual: HAU). We investigated which housing rehabilitation setting is effective on which variable in the long term to support service users to form an informed preference for either housing rehabilitation setting. Methods We conducted a two-year longitudinal observational non-inferiority study to test the effectiveness of ISH in improving participants’ social inclusion, quality of life, emotional social support, capabilities, symptom severity, functioning, service utilisation and costs. Participants were assessed at baseline and after six, twelve, and 24 months. Mixed effects models were computed to test between-group and within-group effects. Results The study included 83 participants in ISH (n = 31) and HAU (n = 52) housing rehabilitation settings with a mean age of 36.2 years. Most participants were male (64%) and had a primary psychotic or schizophrenic (35%) or an affective diagnosis (24%). During the study, ISH participants significantly improved their quality of life (β = 0.54; 95% CI: 0.26 to 0.82), symptoms (β = -0.32; 95% CI: -0.60 to -0.03), and capabilities (β = 4.46; 95% CI: 0.14 to 8.77) and decreased psychiatric hospitalisations (p = 0.04). HAU participants improved their quality of life (β = 0.40; 95% CI: 0.12 to 0.69). Housing and rehabilitation support costs were almost half with ISH than with HAU. Conclusion ISH has been shown to be much less expensive than HAU and was associated with several improvements like reduced psychiatric hospitalisations and improved quality of life. Therefore, our findings strongly argue for a preference-driven provision of housing rehabilitation services and to end the institutionalisation of persons with SMI. Trial registration The study was registered on December 04, 2018, at ClinicalTrials.gov (NCT03815604).

Background: In the Netherlands, physician-assisted death (PAD) is allowed under certain conditions. Patients who suffer from mental illnesses are not excluded from this practice. In 2018, general practitioners (GPs) performed 20 out of a total of 67 cases of EAS for psychiatric suffering., Objective: More insight into GPs' experiences and views with regard to PAD in psychiatry., Design: The data for this study were obtained through a survey amongst 500 randomly selected Dutch GPs and by in-depth interviews with 20 Dutch GPs., Setting: A survey study and in-depth interviews., Subjects: Dutch GPs., Results: 86 out of 101 GPs found it conceivable to perform EAS in case of somatic disease, and 51 out of 104 GPs found it conceivable in the case a patient suffered from a mental illness only. The main reason given for refusing an PAD request was that the criteria of due care were not met. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide. Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy., Conclusion: GPs are less likely to perform PAD for suffering from a mental illness, compared to somatic suffering. Some GPs apply an extra criterion of 'life-expectancy' in case of PAD for suffering from a mental illness. Refusing PAD based on a long life expectancy keeps open the possibility of recovery, but may also just prolong the suffering and add to the unbearableness of it.KEY POINTSCurrently, there is no qualitative research on what the views are of general practitioners regarding the subject of physician-assisted death (PAD) for patients suffering from severe mental disorders.General practitioners are less likely to consider a request for physician-assisted death by a patient suffering from a psychiatric disorder, compared to somatic suffering. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide.Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.Significance for the reader: Although allowed in the Netherlands, PAD in case of severe mental suffering remains a controversial topic. We need in-depth information about the actual practice of it to have an informed debate with regard to this subject.

Objectives: The side effects of antipsychotic medications (APs) can increase the risk of developing physical health conditions. Some APs pose a higher risk than others. Evidence suggests switching to lower risk APs can support physical health outcomes. We sought to explore the views of healthcare professionals about switching antipsychotics to support physical health in people with severe mental illness (SMI)., Design: A qualitative study with semi-structured interviews conducted with general practitioners (GPs), psychiatrists and mental health nurses. The main focus was to explore participants' views on the physical health of people with SMI, the impact of APs and decision-making about switching medication to support physical health. Data were analysed thematically using principles of constant comparison., Settings: Participants recruited through primary care and one mental health trust in the West Midlands., Participants: Interviews were conducted with 9 GPs, 10 psychiatrists and 4 mental health nurses., Results: Awareness and knowledge of AP side-effects and risk profiles varied considerably between primary and secondary care clinicians. GPs reported limited awareness, while psychiatrists and nurses demonstrated a comprehensive understanding of AP risk profiles and side-effects. Mental health and control of symptoms were prioritised. Switching to promote physical health was considered as a reactive intervention, once side-effects or complications developed. There were a range of views over where responsibility lay for monitoring physical health and consideration of switching. Collaboration between primary and secondary care was identified as a way to address this., Conclusions: This study presents multidisciplinary perspectives on awareness, decision making, perceived responsibility and barriers to switching APs to support physical health. Collaborative approaches that involve liaison between primary and secondary care, but tailored to the individual patient, may support switching, and present an opportunity to intervene to address the physical health inequalities experienced by individuals with SMI., Competing Interests: Competing interests: Sunovian Pharmaceuticals funded this work; however, the conduct of the research, data collection, analysis and drafting of this manuscript were completed independently by the research team. No members of the research team have a financial relationship with Sunovian Pharmaceuticals., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

BackgroundPeople with severe mental illness experience physical health inequalities and a 15–20-year premature mortality rate. Forensic inpatients are particularly affected by restrictions on movement, long admissions, and obesogenic/sedative psychotropic medication. We aimed to establish the feasibility and acceptability of Motiv8, a multidisciplinary weight management intervention co-produced with service users for forensic inpatients.MethodsA randomised waitlist-controlled trial of Motiv8(+Treatment-As-Usual) vs.TAU was conducted in medium-secure forensic services in Greater Manchester. Motiv8 is a 9-week programme of exercise sessions, diet/cooking classes, psychology, physical health/sleep education, and peer support. Physical and mental health assessments were conducted at baseline/10-weeks/3-months. A nested qualitative study captured participant experiences. A staff sub-study explored ward environment.ResultsWe aimed to recruit 32 participants (four cohorts). The trial met recruitment targets (n=29, 90.9%; 4 cohorts, 100%), participants were randomised to Motiv8+TAU (n=12) or waitlist (control) (n=17). Acceptable retention rates were observed (93.1%, 10-weeks; 72.4%, 3-months), and participants engaged well with the intervention. The blind was maintained, and no safety concerns raised. Assessment completion was high suggesting acceptability (>90% for people retained and engaged in the study). Participants reported high levels of satisfaction.ConclusionsThe trial was not powered to detect group differences. However, data suggests it is feasible to conduct a rigorous, methodologically robust study of Motiv8 vs.TAU for adults on forensic inpatient units. Motiv8 was acceptable with potential promise providing evidence to proceed to a definitive trial for males. A larger trial is needed to explore potential effectiveness and reduce physical health inequalities for people with SMI.Clinical trial registrationhttps://doi.org/10.1186/ISRCTN13539285, identifier ISRCTN13539285.

Abstract Introduction People with severe mental illness (SMI) face a higher risk of premature mortality due to physical morbidity compared to the general population. Establishing regular contact with a general practitioner (GP) can mitigate this risk, yet barriers to healthcare access persist. Population initiatives to overcome these barriers require efficient identification of those persons in need. Objective To develop a predictive model to identify persons with SMI not attending a GP regularly. Method For individuals with psychotic disorder, bipolar disorder, or severe depression between 2011 and 2016 (n = 48,804), GP contacts from 2016 to 2018 were retrieved. Two logistic regression models using demographic and clinical data from Danish national registers predicted severe mental illness without GP contact. Model 1 retained significant main effect variables, while Model 2 included significant bivariate interactions. Goodness-of-fit and discriminating ability were evaluated using Hosmer-Lemeshow (HL) test and area under the receiver operating characteristic curve (AUC), respectively, via cross-validation. Results The simple model retained 11 main effects, while the expanded model included 13 main effects and 10 bivariate interactions after backward elimination. HL tests were non-significant for both models (p = 0.50 for the simple model and p = 0.68 for the extended model). Their respective AUC values were 0.789 and 0.790. Conclusion Leveraging Danish national register data, we developed two predictive models to identify SMI individuals without GP contact. The extended model had slightly better model performance than the simple model. Our study may help to identify persons with SMI not engaging with primary care which could enhance health and treatment outcomes in this group.

Abstract Background Clients with severe mental illness (SMI) have overall poor physical health. SMI reduces life expectancy by 5–17 years, primarily due to physical comorbidity linked to cardiometabolic risks that are mainly driven by unhealthy lifestyle behaviours. To improve physical health in clients with SMI, key elements are systematic somatic screening and lifestyle promotion. The nurse-led GILL eHealth was developed for somatic screening and the implementation of lifestyle activities in clients with SMI. Aims of this study are to evaluate the effectiveness of the GILL eHealth intervention in clients with SMI compared to usual care, and to evaluate the implementation process, and the experiences of clients and healthcare providers with GILL eHealth. Methods The GILL study encompasses a cluster-randomised controlled trial in approximately 20 mental health care facilities in the Netherlands. The randomisation takes place at the team level, assigning clients to the eHealth intervention or the usual care group. The GILL eHealth intervention consists of two complementary modules for somatic screening and lifestyle promotion, resulting in personalised somatic treatment and lifestyle plans. Trained mental health nurses and nurse practitioners will implement the intervention within the multidisciplinary treatment context, and will guide and support the participants in promoting their physical health, including cardiometabolic risk management. Usual care includes treatment as currently delivered, with national guidelines as frame of reference. We aim to include 258 clients with SMI and a BMI of 27 or higher. Primary outcome is the metabolic syndrome severity score. Secondary outcomes are physical health measurements and participants’ reports on physical activity, perceived lifestyle behaviours, quality of life, recovery, psychosocial functioning, and health-related self-efficacy. Measurements will be completed at baseline and at 6 and 12 months. A qualitative process evaluation will be conducted alongside, to evaluate the process of implementation and the experiences of clients and healthcare professionals with GILL eHealth. Discussion The GILL eHealth intervention is expected to be more effective than usual care in improving physical health and lifestyle behaviours among clients with SMI. It will also provide important information on implementation of GILL eHealth in mental health care. If proven effective, GILL eHealth offers a clinically useful tool to improve physical health and lifestyle behaviours. Trial registration Clinical trial registration NCT05533749, registration date: 8 September 2022.

Abstract Background Stage of Recovery Instrument-30 (STORI-30) is grounded in a five-stage model of psychological recovery, and serves as measuring recovery stage of people with mental illness. Aims To develop and validate the Chinese version STORI-30 on adults with severe mental illness. Methods STORI-30 was translated to traditional Chinese through forward-backward method. An expert panel and potential users evaluated face validity and content validity. The Chinese version STORI-30 plus other convergent and divergent scales were then administered to 113 participants for field test. Results Face and content validity were confirmed with acceptable Content Validity Index and high inter-rater agreement. Exploratory factor analysis revealed a three-factor structure. An ordinal sequence was presented among the five subscales, similar to the original version. Construct validity was supported by positive correlations with recovery and mental well-being scales, and negative correlation with self-stigma scale. Good internal consistency (Cronbach’s α = 0.78–0.86) and high level of test-retest reliability (Intraclass correlation coefficient = 0.96) were obtained. Conclusions Chinese STORI-30 presents satisfactory psychometric properties in internal consistency, construct convergent and divergent validity, and test-retest reliability. The three-factor structure revealed does not echo the original five-stage recovery model. Further studies exploring the underlying structure are warranted.

Background: Treatment rates for severe mental illness (SMI) are low in low- and middle-income countries because of limited resources. Enlisting family support could be effective and low cost in improving patient outcomes. Aim: The article assess the feasibility, acceptability and estimates of efficacy of Family Psychosocial Involvement Intervention (FAPII) for patients with SMI. Setting: Masaka Regional Referral Hospital and Mityana District Hospital in Uganda. Methods: This was a controlled pilot study with two sites randomly assigned as intervention and control. Thirty patients each with one or two family members and six mental health professionals were recruited at the intervention site. Five patients, their family members and two mental health professionals met monthly for 6 months to discuss pre-agreed mental health topics. Patient outcomes were assessed at baseline, 6- and 12-months and analysed using paired t-tests. The trial was prospectively registered (ISRCTN25146122). Results: At 6 and 12 months, there was significant improvement in the QoL in the intervention group compared to the control (p = 0.001). There was significant symptom reduction in the intervention group at 6 and 12 months (p 0.001). Family Psychosocial Involvement Intervention affected better treatment adherence at 6 and 12 months (p = 0.035 and p 0.001, respectively) compared to the control arm. Conclusion: Family Psychosocial Involvement Intervention improved QoL, medication adherence, reduced stigma and symptoms among patients with SMI. The authors recommend involving families in the care of patients with SMI in Uganda, with FAPII employing culturally sensitive psychotherapy. Contribution: The results support involvement of family in the care of patients with SMI.

Objective: This study's purpose was to examine attitudes and perceptions of resident psychiatrists regarding the sexual and reproductive health needs of their female patients with severe mental illness. The three aims were to investigate resident psychiatrists' (1) perceptions regarding the importance of providing sexual and reproductive health services to female patients in the outpatient behavioral health setting, (2) current engagement in providing sexual and reproductive health services to their female patients, and (3) perceived barriers and facilitators to addressing sexual and reproductive health in this vulnerable patient population., Methods: Fifteen resident psychiatrists were recruited from the behavioral health clinic at a safety-net public sector hospital for a structured interview. Interviews were recorded, transcribed, and then coded using MAXQDA© software., Results: Resident psychiatrists recognized the importance of addressing sexual and reproductive health with their female patients and recognized their hypothetical ability to provide sexual and reproductive health counseling and services based on their training and resources. However, residents reported rarely providing these services, mostly addressing sexual and reproductive health only when necessitated by medication changes. Perceived barriers included lack of training or knowledge, discomfort, and limited appointment time., Conclusions: Resident psychiatrists perceive a need to address sexual and reproductive health with their female patients with serious mental illness but lack the confidence and resources to do so. Directed education and clear institutional guidelines are necessary to equip the next generation of psychiatrists with the tools needed to address the sexual and reproductive health needs of women with serious mental illness.

Pregnancy brings joy and excitement to some women, but great distress to those who suffer from severe mental illnesses like schizophrenia. Women with severe mental illnesses (SMIs) may have difficulty planning a pregnancy and deciding whether to continue to viability, and thence to term. Dilemmas also surround pharmacotherapy for this population, as (non)treatment is associated with its own challenges. The psychiatrist may have to make challenging decisions based on the principles of autonomy, beneficence, and relational ethics. Furthermore, there are ethical controversies inherent to the underlying pathologies, their non-treatment, and the various psychosocial factors that could impact parenting in such mothers. In addition, limited or ineffective use of family planning, mental health services, and contraception often act as forerunners of these problems. Considering the sparse literature on this topic and the perplexing legal responsibilities pertaining to the recently implemented Mental Health Care Act, 2017, we have attempted to highlight the various ethical dilemmas that confront a psychiatrist while managing a patient from this group Keywords: pregnancy, perinatal, severe mental illness, schizophrenia, psychosis, ethics.

BackgroundMood disorders such as major depressive and bipolar disorders, along with posttraumatic stress disorder (PTSD), schizophrenia (SCZ), and other psychotic disorders, constitute serious mental illnesses (SMI) and often lead to inpatient psychiatric care for adults. Risk factors associated with increased hospitalization rate in SMI (H-SMI) are largely unknown but likely involve a combination of genetic, environmental, and socio-behavioral factors. We performed a genome-wide association study in an African American cohort to identify possible genes associated with hospitalization due to SMI (H-SMI).MethodsPatients hospitalized for psychiatric disorders (H-SMI; n=690) were compared with demographically matched controls (n=4467). Quality control and imputation of genome-wide data were performed following the Psychiatric Genetic Consortium (PGC)-PTSD guidelines. Imputation of the Human Leukocyte Antigen (HLA) locus was performed using the HIBAG package.ResultsGenome-wide association analysis revealed a genome-wide significant association at 6p22.1 locus in the ubiquitin D (UBD/FAT10) gene (rs362514, p=9.43x10-9) and around the HLA locus. Heritability of H-SMI (14.6%) was comparable to other psychiatric disorders (4% to 45%). We observed a nominally significant association with 2 HLA alleles: HLA-A*23:01 (OR=1.04, p=2.3x10-3) and HLA-C*06:02 (OR=1.04, p=1.5x10-3). Two other genes (VSP13D and TSPAN9), possibly associated with immune response, were found to be associated with H-SMI using gene-based analyses.ConclusionWe observed a strong association between H-SMI and a locus that has been consistently and strongly associated with SCZ in multiple studies (6p21.32-p22.1), possibly indicating an involvement of the immune system and the immune response in the development of severe transdiagnostic SMI.

Abstract Background Despite the increasing use of comprehensive rehabilitation models for people with severe mental illness (SMI), there are still limitations to their implementation and replicability in a consensual way, particularly in Latin American countries. The REINTEGRA program aims to be a standardized model of comprehensive rehabilitation focused on psychosocial and cognitive improvement through a set of interventions on different areas of people’s functionality, with the goal of reintegrating people with SMI into the labour market. In this paper we summarize the protocol for its subsequent implementation in a mental health institution in Mexico. Method The protocol is based on a quasi-experimental, prospective longitudinal study, with a pragmatic or naturalistic control group. It will be carried out in three phases. Phase 1 consists of a series of interventions focused on psychosocial improvement; Phase 2 focuses on cognitive and behavioral improvement treatments; and Phase 3 targets psychosocial recovery through rehabilitation and reintegration into the labour market. The overall procedure will be monitored with standarized evaluations at different stages of the program. Discussion This study presents a model of integral rehabilitation of people with SMI. At the moment, one of the obstacles to overcome is the organization and procedural control of the different actors needed for its implementation (nurses, psychologists, doctors, companies, institutions, etc.). REINTEGRA will be the first comprehensive rehabilitation model that includes systematized procedures for job reinsertion for people with SMI in Mexico, which aims to be a standardized tool of easy adaptation and the replicability for other mental health centers and institutions.

Abstract Background Deinstitutionalization in mental health care has been an ongoing process for decades. More and more people with severe mental illness (SMI), who previously lived in residential supported housing settings and were formerly homeless, are now living independently in the community but need intensive support to enable independent living. The support provided by regular outpatient teams is inadequate for this target group. This study explored the ingredients for an alternative form of outpatient support: intensive home support (IHS). Methods Concept mapping was used, following five steps: (1) brainstorming, (2) sorting, (3) rating, (4) statistical analysis & visual representation, and (5) interpretation. Purposive sampling was used to represent several perspectives, including researchers, professionals, peer workers, and policy makers. Results Experts (n = 17) participated in the brainstorming step and the sorting and rating steps (n = 14). The 84 generated statements were grouped into 10 clusters:. (1) housing rights; (2) informal collaboration; (3) reciprocity in the community; (4) normalization and citizenship; (5) recovery; (6) sustainable funding; (7) equivalence; (8) flexible, proactive 24/7 support; (9) public health and positive health; and (10) integrated cooperation in support at home. Conclusions Given the diversity of the ingredients contained in the clusters, it seems that IHS should be designed according to a holistic approach in collaboration with several sectors. Additionally, IHS is not only the responsibility of care organizations but also the responsibility of national and local governments. Further research about collaboration and integrated care is needed to determine how to implement all of the ingredients in practice.

Abstract Background Children of parents with a severe mental illness have an increased risk of developing a lifetime mental illness. We aimed to compare the effects of a preventive family‐based intervention, VIA Family, with treatment as usual (TAU) on these children's global functioning. Methods Between 2017 and 2021, we conducted a pragmatic, rater‐blinded, two‐arm parallel‐group superiority trial in Denmark. Families with at least one child aged 6–12 years and at least one biological parent with schizophrenia spectrum disorder, bipolar disorder, or recurrent major or moderate depression were included. We randomly allocated 95 families with their 113 children to VIA Family or TAU (ratio 1:1). VIA Family was individually tailored and based on case management. The intervention included options for psychoeducation, parental support, and treatment for emerging child psychiatric symptoms. Blinded raters assessed children and their families at baseline and after 18 months. The primary outcome was the difference in change between groups at end‐of‐treatment in daily global functioning measured with the Children's Global Assessment Scale. Secondary outcomes were emotional and behavioral problems and days absent from school. We analyzed data blinded to allocation. Results At post‐intervention, differences in mean change from baseline between VIA Family and TAU were non‐significant (CGAS: −1.20, 95% CI = −6.61; 4.21, p = 0.66), as were the differences on the secondary and exploratory outcomes. Conclusion Contrary to our hypothesis, we did not find a superior effect of VIA Family compared with TAU. The short follow‐up period and large sample heterogeneity might explain the null findings. Therefore, a possible long‐term, preventive treatment effect has yet to be explored.

Background People with severe mental illness (SMI) have worse physical health than the general population. There is evidence that support from volunteers can help the mental health of people with SMI, but little evidence regarding the support they can give for physical health. Aims To evaluate the feasibility of an intervention where volunteer ‘Health Champions’ support people with SMI in managing their physical health. Method A feasibility hybrid randomised controlled trial conducted in mental health teams with people with SMI. Volunteers delivered the Health Champions intervention. We collected data on the feasibility of delivering the intervention, and clinical and cost-effectiveness. Participants were randomised by a statistician independent of the research team, to either having a Health Champion or treatment as usual. Blinding was not done. Results We recruited 48 participants: 27 to the intervention group and 21 to the control group. Data were analysed for 34 participants. No changes were found in clinical effectiveness for either group. Implementation outcomes measures showed high acceptability, feasibility and appropriateness, but with low response rates. No adverse events were identified in either group. Interviews with participants found they identified changes they had made to their physical health. The cost of implementing the intervention was £312 per participant. Conclusions The Health Champion intervention was feasible to implement, but the implementation of the study measures was problematic. Participants found the intervention acceptable, feasible and appropriate, and it led them to make changes in their physical health. A larger trial is recommended, with tailored implementation outcome measures.

IntroductionIn the Western world, more than one-third of the patients of productive age hospitalized for severe mental illness (SMI) are parents. Each of their offspring is exposed to several stressors related to their parent’s illness and hospitalization, which puts them at an increased risk of developing mental health problems. In the Czech Republic, no statistics are currently available about the families of patients with SMI, inpatients who are parents, or data about their children (ages ≤18 years). Therefore, our research aim was to describe the prevalence of parenthood among hospitalized patients with SMI, assess the number of children and determine the extent to which offspring information was present in medical records.MethodsQuantitative data from medical records (2,768 patients, aged 18–63 years, hospitalized for SMI between 2017 and 2020) from two large inpatient psychiatric facilities were examined. Parental information, demographic characteristics, number of children, and other available data were collected.ResultsThe prevalence of parenthood among inpatients with SMI was 34.6%. Parenthood was most prevalent among female patients and patients with recurrent depressive and bipolar disorders. The total number of offspring in 957 patient-parents was 1781 (41.7% minors under the age of 18). Information on parenthood was available in 99.7% of cases; information on the age of offspring, custody, and sociodemographic situation varies, being included in 73% to 89.7% of the medical records (some details were more frequently recorded than others).DiscussionThe data obtained may help to better understand and address the specifics of these families and thus serve as a basis for the development of prevention programs.

Background Severe mental illness (SMI) is associated with significant morbidity. Frailty combines biological ageing, comorbidity and psychosocial factors and can predict adverse health outcomes. Emerging evidence indicates that frailty is higher in individuals with SMI than in the general population, although studies have been limited by sample size. Aims To describe the prevalence of frailty in people with SMI in a large cohort using three different frailty measures and examine the impact of demographic and sociodemographic variables. Method The UK Biobank survey data, which included individuals aged 37–73 years from England, Scotland and Wales from 2006 to 2010, with linked in-patient hospital episodes, were utilised. The prevalence of frailty in individuals with and without SMI was assessed through three frailty measures: frailty index, physical frailty phenotype (PFP) and Hospital Frailty Risk Score (HFRS). Stratified analysis and dichotomous logistic regression were conducted. Results A frailty index could be calculated for 99.5% of the 502 412 UK Biobank participants and demonstrated greater prevalence of frailty in women and an increase with age. The prevalence of frailty for those with SMI was 3.19% (95% CI 3.0–3.4), 4.2% (95% CI 3.8–4.7) and 18% (95% CI 15–23) using the frailty index, PFP and HFRS respectively. The prevalence ratio was between 3 and 18 times higher than in those without SMI. Conclusions As a measure, frailty captures the known increase in morbidity associated with SMI and may potentially allow for earlier identification of those who will benefit from targeted interventions.

Background: Due to increased cardiometabolic risks and premature mortality in people with severe mental illness (SMI), monitoring cardiometabolic health is considered essential. We aimed to analyse screening rates and prevalences of cardiometabolic risks in routine mental healthcare and its associations with patient and disease characteristics. Methods: We collected screening data in SMI from three mental healthcare institutions in the Netherlands, using most complete data on the five main metabolic syndrome (MetS) criteria (waist circumference, blood pressure, HDL-cholesterol, triglycerides, fasting blood glucose) within a 30-day timeframe in 2019/2020. We determined screened patients' cardiometabolic risks and analysed associations with patient and disease characteristics using multiple logistic regression. Results: In 5037 patients, screening rates ranged from 28.8% (waist circumference) to 76.4% (fasting blood glucose) within 2019–2020, and 7.6% had a complete measurement of all five MetS criteria. Older patients, men and patients with psychotic disorders had higher odds of being screened. Without regarding medication use, risk prevalences ranged from 29.6% (fasting blood glucose) to 56.8% (blood pressure), and 48.6% had MetS. Gender and age were particularly associated with odds for individual risk factors. Cardiometabolic risk was present regardless of illness severity and did generally not differ substantially between diagnoses, in−/outpatients and institutions. Conclusions: Despite increased urgency and guideline development for cardiometabolic health in SMI last decades, screening rates are still low, and the MetS prevalence across screened patients is almost twice that of the general population. More intensive implementation strategies are needed to translate policies into action to improve cardiometabolic health in SMI.

Abstract People with severe mental illness (SMI) have a higher prevalence of obesity as compared with the general population, however, there is mixed evidence about the prevalence of underweight. Thus, the aim of this study is to determine the pooled prevalence of underweight in people with SMI and its association with socio‐demographic factors; and to compare the prevalence of underweight between SMI and the general population. MEDLINE, PsycINFO, and EMBASE databases were searched to identify observational studies assessing the prevalence of underweight in adults with SMI (schizophrenia, major depressive disorder with psychotic features, and bipolar disorders). Screening, data extraction, and risk of bias assessments were performed independently by two co‐authors, with disagreements resolved by consensus. Random effect estimates for the pooled prevalence of underweight and the pooled odds of underweight in people with SMI compared with the general population were calculated. Subgroup analyses were conducted for the type of SMI, setting, antipsychotic medication, region of the world, World Bank country income classification, data collection, and sex. Forty estimates from 22 countries were included. The pooled prevalence of underweight in people with SMI was 3.8% (95% confidence interval [CI] = 2.9–5.0). People with SMI were less likely to be underweight than the general population (odds ratio [OR] 0.65; 95% CI = 0.4–1.0). The pooled prevalence of underweight in SMI in South Asia was 7.5% (95% CI = 5.8–14.1) followed by Europe and Central Asia at 5.2% (95% CI = 3.2–8.1) and North America at 1.8% (95% CI = 1.2–2.6). People with SMI have lower odds of being underweight compared to the general population. People with schizophrenia had the highest prevalence of underweight compared to other types of SMI. Japan and South Asia have the highest prevalence of underweight in people with SMI.

Abstract Background Smoking among people with severe mental illness (SMI) is highly prevalent and strongly associated with poor physical health. Currently, evidence-based smoking cessation interventions are scarce and need to be integrated into current mental health care treatment guidelines and clinical practice. Therefore, the present study aims to evaluate the implementation and effectiveness of a smoking cessation intervention in comparison with usual care in people with SMI treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands. Methods A pragmatic, cluster-randomised controlled trial with embedded process evaluation will be conducted. Randomisation will be performed at the level of FACT teams, which will be assigned to the KISMET intervention or a control group (care as usual). The intervention will include pharmacological treatment combined with behavioural counselling and peer support provided by trained mental health care professionals. The intervention was developed using a Delphi study, through which a consensus was reached on the core elements of the intervention. We aim to include a total of 318 people with SMI (aged 18–65 years) who smoke and desire to quit smoking. The primary outcome is smoking status, as verified by carbon monoxide measurements and self-report. The secondary outcomes are depression and anxiety, psychotic symptoms, physical fitness, cardiovascular risks, substance use, quality of life, and health-related self-efficacy at 12 months. Alongside the trial, a qualitative process evaluation will be conducted to evaluate the barriers to and facilitators of its implementation as well as the satisfaction and experiences of both patients and mental health care professionals. Discussion The results of the KISMET trial will contribute to the evidence gap of effective smoking cessation interventions for people treated by FACT teams. Moreover, insights will be obtained regarding the implementation process of the intervention in current mental health care. The outcomes should advance the understanding of the interdependence of physical and mental health and the gradual integration of both within the mental health care system. Trial registration Netherlands Trial Register, NTR9783. Registered on 18 October 2021.

IntroductionExternal stressors, such as COVID-19 pandemic and earthquake, can cause an increase in substance use and addictive behavior in persons with severe mental illnesses (SMI). We analyzed the changes and predictors of substance use and addictive behavior in SMI during these double disasters in Croatia.MethodsQuestionnaires exploring the presence of substance or behavior addiction disorder, mental ill health [Depression Anxiety Stress Scales-21 (DASS-21), Insomnia Severity Index (ISI), Perceived Stress Scale (PSS), Obsessive-Compulsive Inventory-Revised], coping mechanisms, and perceived social support [Multidimensional Scale of Perceived Social Support (MSPSS)] were administered among 90 participants with SMI included in the RECOVER-E study in May/June 2020 (first COVID-19 wave, Zagreb earthquake) and in December 2020/January 2021 (second COVID-19 wave, Petrinja earthquake).ResultsIn both time points, a major increase was observed in tobacco smoking (25.0%; 28.6%, respectively) predicted by discontinuation of antidepressants and higher DASS-21 score. Increased sedative use was observed (24.4%; 23.8%, respectively) predicted by higher PSS and ISI scores, lower MSPSS scores, antipsychotic discontinuation and not receiving community mental health team (CMHT) service.DiscussionIn persons with SMI during a double disaster special attention needs to be given to reducing mental-ill health and stress, providing social support and continuity of psychiatric care, through medications and CMHTs.

Abstract Background As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented. Aim To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation. Methods/design A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members. Discussion The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Aims To understand the challenges and barriers experienced by health-care professionals (HCPs) in providing acute cardiac care to patients with severe mental illness (SMI) (schizophrenia, bipolar disorder or severe depression) admitted to hospital following a myocardial infarction (MI). Methods Semi-structured 1:1 videocall interviews with 12 HCPs in two central-Scotland Health Boards involved in delivering pre-/hospital acute care for a MI (paramedics, cardiology/A&E nurses, cardiology/A&E doctors). Interviewee recruitment was via clinical and research networks and newsletters e.g. the Scottish Ambulance Service, the Royal College of Nursing and Royal College of Physicians and through professional connections. Interviews were audio-recorded, transcribed verbatim and analysed thematically drawing on Braun & Clarke and using NVivo software. Results HCPs identified a number of challenges/barriers to providing optimal post-MI acute cardiac care to patients with a SMI across 3 key themes: patient-related; practitioner-related and system/environment-related. Core patient-related challenges/barriers included: diminished patient history capacities especially relating to chronology; the time-consuming nature of effective HCP-patient communication and engagement; medication and intervention concordance concerns and challenging patient behaviour including physical and verbal aggression or severe distress. Practitioner-related challenges/barriers were: fears of appropriately managing patient behaviour; stigma towards patients with a SMI (putatively arising from knowledge deficits or generational/age-related effects); staff burnout due to length of service and pressures from extreme workloads. Systemic issues included insufficient staffing precluding the additional time required for effective communication and the distressing nature of hospital environments for patients with a SMI. Side rooms were not routinely available even though these were identified as improving the environment for some patients. A core systemic finding, cited by all interviewees, was the lack of adequate training provision on caring for patients with a SMI. Additional system-level findings were degrees of challenges accessing input from the hospital psychiatric team especially outwith standard hours and problems obtaining rarer psychiatric medications potentially impacting patients’ mental health stability. Positive findings included that HCPs are generally enthusiastic about providing high quality care to this patient group and to seek help with this. Some HCPs indicated that caring for mentally stable patients with a SMI does not differ from the general population. Conclusion Although HCPs aspired to providing optimal acute cardiac care for this patient group, patient-level, professional and systemic barriers often make this challenging. A key area for improvement is enhancing staff training in caring for patients with SMI, ideally delivered in-person.

Abstract Background People with severe mental illness (SMI) often suffer from long-lasting symptoms that negatively influence their social functioning, their ability to live a meaningful life, and participation in society. Interventions aimed at increasing physical activity can improve social functioning, but people with SMI experience multiple barriers to becoming physically active. Besides, the implementation of physical activity interventions in day-to-day practice is difficult. In this study, we aim to evaluate the effectiveness and implementation of a physical activity intervention to improve social functioning, mental and physical health. Methods In this pragmatic stepped wedge cluster randomized controlled trial we aim to include 100 people with SMI and their mental health workers from a supported housing organization. The intervention focuses on increasing physical activity by implementing group sports activities, active guidance meetings, and a serious game to set physical activity goals. We aim to decrease barriers to physical activity through active involvement of the mental health workers, lifestyle courses, and a medication review. Participating locations will be divided into four clusters and randomization will decide the start of the intervention. The primary outcome is social functioning. Secondary outcomes are quality of life, symptom severity, physical activity, cardiometabolic risk factors, cardiorespiratory fitness, and movement disturbances with specific attention to postural adjustment and movement sequencing in gait. In addition, we will assess the implementation by conducting semi-structured interviews with location managers and mental health workers and analyze them by direct content analysis. Discussion This trial is innovative since it aims to improve social functioning in people with SMI through a physical activity intervention which aims to lower barriers to becoming physically active in a real-life setting. The strength of this trial is that we will also evaluate the implementation of the intervention. Limitations of this study are the risk of poor implementation of the intervention, and bias due to the inclusion of a medication review in the intervention that might impact outcomes. Trial registration This trial was registered prospectively in The Netherlands Trial Register (NTR) as NTR NL9163 on December 20, 2020. As the The Netherlands Trial Register is no longer available, the trial can now be found in the International Clinical Trial Registry Platform via: https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163 .

Aims The Mediterranean diet has shown to improve mental health outcomes in people with depressive disorder. However, little is known of the impact of the Mediterranean diet on severe mental illness. The aim of this systematic review was to evaluate the impact of a Mediterranean diet on mental health and quality of life outcomes in adolescents and adults with severe mental illness (as defined by schizophrenia spectrum disorders, at risk mental states for psychosis, bipolar affective disorder and severe depression with psychosis). Methods The following databases were systematically searched: MEDLINE and EMBASE via Ovid, CINAHL via EBSCO, PsychInfo via ProQuest, PubMed and Clinicaltrials.gov, using relevant subject headings and free text search terms to encompass severe mental illness and the Mediterranean diet. Screening, data extraction and quality assessment were completed by two independent reviewers. Eligible study designs included randomised controlled trials, other non-controlled or controlled interventional or experimental studies, cohort studies, case-control studies and cross-sectional studies that included adults and adolescents. The search was not limited to a specific time frame or language. The Mediterranean diet and mental health and quality of life outcomes were defined by primary paper author definitions. Results Thirteen eligible studies were identified: 4 interventional, 2 cohort, 2 case-control and 4 cross-sectional studies and 1 mixed methods (interventional and observational) study. Diagnoses in most studies were psychotic illness, schizophrenia, schizoaffective disorder, bipolar affective disorder and depression with psychosis. There was a lack of studies found that included adolescents or participants with at-risk mental states for psychosis. A range of Mediterranean diet adherence scoring systems were used across studies, indicating a notable heterogeneity in the way adherence was evaluated. Most studies included other lifestyle exposures or interventions alongside the Mediterranean diet. There was a marked heterogeneity between studies in how mental health and quality of life outcomes were assessed. Although there was an overall trend towards improved mental health or quality of life outcomes in some studies, others reported no change or a negative association with the dietary/lifestyle exposure or intervention. Conclusion The association between Mediterranean diet adherence and mental health outcomes and quality of life in adults and adolescents with severe mental illness remains inconsistent. Lifestyle-based interventions for the treatment of mental illness are cost-effective and relatively easy to implement with less concern about side effects. Therefore, this area requires further research.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) was implemented in a community mental health center (CMHC) setting. The goal of TranS-C is to improve sleep and circadian dysfunction among people with severe mental illness. The present study uses the Theoretical Domains Framework (TDF) to uncover barriers and facilitators to changing behaviors learned in TranS-C. Adults with severe mental illness who completed TranS-C (n = 14) were given a semi-structured interview based on the TDF. Interview transcripts were independently coded using inductive and deductive coding. The most commonly coded TDF domains were Behavior Regulation, Beliefs about Consequences, Knowledge and Beliefs about Capabilities. Action planning was the most discussed facilitator and compromising sleep health in favor of time spent with loved ones was the most discussed barrier. These findings suggest that TranS-C has promising strengths and raise important barriers that can be addressed in TranS-C to improve its fit within CMHCs.

Abstract Aims This study aimed to conduct a systematic review of studies on the outcomes of long-term hospitalisation of individuals with severe mental illness, considering readmission rates as the primary outcome. Methods Studies considered were those in which participants were aged between 18 and 64 years with severe mental illness; exposure to psychiatric hospitals or wards was long-term (more than one year); primary outcomes were readmission rates; secondary outcomes were duration of readmission, employment, schooling, and social participation; and the study design was either observational or interventional with a randomised controlled trial (RCT) design. Relevant studies were searched using MEDLINE, PsycINFO, Web of Science, CINAHL, and the Japan Medical Abstract Society. The final search was conducted on 1 February 2022. The risk of bias in non-randomised studies of interventions was used to assess the methodological quality. A descriptive literature review is also conducted. Results Of the 11,999 studies initially searched, three cohort studies (2,293 participants) met the eligibility criteria. The risk of bias in these studies was rated as critical or serious. The 1–10 years readmission rate for patients with schizophrenia who had been hospitalised for more than one year ranged from 33 to 55%. The average of readmission durations described in the two studies was 70.5 ± 95.6 days per year (in the case of a 7.5-year follow-up) and 306 ± 399 days (in the case of a 3–8-year follow-up). None of the studies reported other outcomes defined in this study. Conclusions The readmission rates in the included studies varied. Differences in the follow-up period or the intensity of community services may have contributed to this variability. In countries preparing to implement de-institutionalisation, highly individualised community support should be designed to avoid relocation to residential services under supervision. The length of stay for readmissions was shorter than that for index admissions. The results also imply that discharge to the community contributes to improved clinical outcomes such as improved social functioning. The validity of retaining patients admitted because of the risk of rehospitalisation was considered low. Future research directions have also been discussed.