The Birth Project, an IMH collaborative research project with the University of Derby, is looking to recruit both midwives (students, practising, retired) and women who have given birth in the past 5 years  for 'The Birth Project, researching the birth event through visual methods'.  More details, including how to get involved,  are below: Midwives (students, practising, retired)   Women who have given birth in the past 5 years

All of us who work within or who use mental health services are well-aware of the stigma that continues to surround mental health conditions and how it affects patients and their carers, preventing them from accessing support, making it difficult for them to enter or re-enter the workforce and how it saps at quality of life in a way that can make the stigma around mental  illness almost as disabling, and perhaps at times worse, than the illness itself.

At the same time, we are facing austerity drives that are leading to cuts and closures to mental health services. There is a national adult inpatient crisis. Against this background, we have to ask whether the generously funded anti-stigma campaign ‘Time to Change’ is working and whether it is value for money. This is not a popular question to ask. However, the analysis that ‘Time to Change’ has been subject to makes it easier to address.

A relevant starting point might be to ask whether any anti-stigma campaign has ever worked in mental health. The history of systematic attempts to de-stigmatise mental illness goes back to the 1950s when a psychiatrist and sociologist couple attempted to change the views of the folk of a Canadian town by presenting information about mental illness - unfortunately rather than de-stigmatise the condition they found that their attempts attracted hostility. 25 years later - another research group found that attitudes towards the mentally ill in that town had not shifted in that time. The World Psychiatric Associated launched an anti-stigma campaign, ‘Open the Doors’ in the 1990s - again with Canada being a pilot site. They found that there was no change in attitudes even if knowledge about mental health conditions increased. More large-scale projects followed. In the UK, the Royal College of Psychiatrist’s Changing Minds campaign between 1997- 2003 didn’t lead to a change in attitudes and the Scottish ‘See Me….’ campaign of 2002 was difficult to evaluate.

A question that could be asked is if these studies were adequately funded and if their effects were properly analysed. ‘Time to Change’ is the largest ever programme in England that aims to reduce stigma and discrimination against people with mental illness. The first phase between 2008 and 2011 was relatively well funded - £21million pounds from the DH and Lottery funds, led by leading mental health charities and evaluated by the Institute of Psychiatry in London.

The evaluation of the first phase was reported in a British Journal of Psychiatry supplement in April 2013. My reading of this evaluation and the associated editorials is that the project has not been a success.

With regards to public knowledge and reported behaviour the evaluation showed that there was no change. Although mental health service users reported a reduction in discrimination, the target of a 5% reduction was not met, and the percentage of service users who responded to this question was low - around 9%- and White British and women were overrepresented in the respondents. There was no change in the attitudes of professionals and a short-term improvement of the attitudes of medical students didn’t last. The economic evaluation is uncertain with model-estimates ranging from a net-cost to a net benefit of £223 million!

In my, much closer to home, evaluation - on a day in Mid November 2013, not one of the 20 patients admitted on my inpatient ward had heard of the Time to Change campaign and only one member of staff had heard about it (out of about 10 who I asked). Indeed in the past 3 years, not a single patient or carer had ever mentioned the Time to Change campaign to me. The only person who did was a visiting politician.

I’m not sure that TTC had an underlying theory that underlined their campaign and informed their attempts to change attitudes and reduce discrimination. I haven't seen one published.

In a recent issue of the New Republic I came across the work of Daniel Kahneman, an American academic who has explored the process in which people distort knowledge to fit their world-view. Cultural cognition theory might explain why mental health stigma campaigns fail to shift attitudes. Culture shapes world views and just a cursory glance at what’s been happening in our world and how the media reports this demonstrates the scale of the challenge. Media portals of mental illness remain dominated by accounts of violence - the Sun’s recent headline of ‘1200 killed by mental patients’ is a good example of this. But also, a recent You Gov poll (October 2013) showed that the public consider the mentally ill as the most discriminated group in Britain. The dominant political narrative has been of ‘benefit scroungers’ and whether the mentally ill are portrayed as ‘deserving or un-deserving poor’ depends on which newspaper you choose to read. Around Halloween our largest supermarkets marketed costumes based on negative stereotypes of the mentally ill as deranged killers. Although the outcry that followed forced them to apologise - the fact that these products managed to hit the shelves shows how Time to Change message has failed to penetrate. There has been no perceptible shift in the cultural attitudes towards mental illness.

Time To Change isn't sufficiently nuanced - the public equate mental illness with severe depression and psychosis and that’s why the ‘1 in 4’ message that it has championed fails to resonate, indeed I wonder whether it alienates. Perhaps we need to be more specific about what we mean by ‘mental health conditions’ and more sophisticated in targeting the stigma that surrounds each condition rather than try and address all as one group.

Susan Sontag’s work around the myths and metaphors that surround illness is also instructive here - when better treatments for TB, Cancer and HIV became available and accessible the myths that surrounded these illnesses started to clear and stigma reduced.

Mass anti-stigma campaigns against mental illness don’t work. We need a more sophisticated approach, targeting particular illnesses. And more research into treatment; and into the support that works to ensure that people with these conditions are given a voice, enabled to enter work and take part in public life. Locally presented stories are far more powerful in capturing and changing minds than national campaigns. Treating people and helping them get better to pursue their goals might be a better use of available resources and a better advert for anti-stigma work.

Is it time to change how we think about anti-stigma campaigns?

 
The blog was based on arguments presented at a debate at the Royal College of Psychiatrists Trent Division Annual Conference on 20 November 2013.

Arun Chopra
Consultant Psychiatrist

@arun_chopra

The post below was originally posted on the Discursive of Tunbridge Wells, The Salomons blog: Views and commentary on psychology, mental health and other stuff on 29 November 2013 and reposted with permission from the author.
[caption id="attachment_1242" align="alignleft" width="199"] Do professionals always have to wear a mask?
Image: kurogami.com


I innocently posted an item on Twitter the other day about Marsha Linehan, one of the world’s best known clinical psychologists and the creator of Dialectical Behaviour Therapy (DBT). Linehan caused a stir a little over two years ago when she announced that she, like so many of the people she has tried to help, had suffered from the experiences labelled as 'borderline personality disorder' (BPD). Admittedly, Twitter is a volatile medium in which people say many things free of the restraints that a less anonymous conversation might impose. But, even so, I was unprepared for the vitriol with which my tweet was greeted.

Service-users responded immediately and their views were unequivocal.

'It only took her 30 years to come out!' complained one, while another said that surely she could have helped more if she had revealed her own history of mental illness sooner. An attack followed on the merits of DBT, created by Linehan with the aid of insights provided by her own struggle.

Whatever you think of DBT, it’s clear that when a mental health professional 'comes out', it will not necessarily go down well. The issue provokes interesting questions. Why don't professionals with so called 'lived experience' of mental illness and other difficult or traumatising experiences make known their histories more often or more easily? What might make them 'come out' and why would they choose to do so after many years of silent practice?

Linehan apparently spilled the beans after a service-user had asked whether she was 'one of us'. Linehan it seems, was used to answering such questions. But something about that question on that particular day got to her, and she let her secret be known. Her confession included details of frequent and protracted hospitalisation as a young woman, a misdiagnosis of schizophrenia and multiple electroconvulsive treatments. It was a risky admission.

More recently, the CEO of one of our local partner NHS trusts, Lisa Rodrigues, chose to make public her history of bipolar mood swings. Her confession received broad applause from what we might call 'the mental health community'. Nonetheless it was not without its detractors. Some service-users predictably thought it too little, too late. Others, including professionals, pointed to the fact that her imminent retirement meant that now was a safe time for coming clean.

The reasons for concealment might seem obvious. Stigma is frightening, and nobody wishes to invite it. But it's a sad fact that mental health professionals stand accused of colluding with it. Stephen Hinshaw in his book, Breaking the Silence suggests there is a status differential between those who give and those who receive care. The result is a tendency for those in professional and scientific roles to hold to an ‘us versus them’ approach in which users and survivors have the one-down position. Many professionals hide behind a facade of invulnerability and those with histories thus remain ‘other’. The fact that any one of us can develop a mental health problem given the right circumstances, may get lost.

There are many traps the other way, though.  While there may be merit in making wounds explicit, referring to a label can be a tricky business. Using it may invite others, including fellow professionals, to view user/survivor professionals through a particular lens. Do people think you understand their pain better? Or will they confer insight on you that you might not have? Psychiatrists might take the view that the disease is in remission. Once labelled, always labelled and that’s it. Do you then have the strength and resilience to cope with the work you do? As well as unease in the professional world, it may sometimes be difficult to be taken seriously as a user-activist if you’ve enjoyed the privilege of recovery and professional training. Both professionals and service-users may attempt to position a dual status professional in ways that can be both unhelpful and unrealistic.

Some of the most difficult dilemmas may arise from within wounded healers themselves. For some, the gift of recovery exerts what is felt as a responsibility to help those in distress, while for others it is an attempt at making peace with the past. However noble such agendas may be, dual status professionals will need to pay attention to motivations that may lead to unhelpful pressures from either themselves or colleagues. Hinshaw suggests that many individuals who enter the mental health professions do so at least in part to examine their own (or their family’s) psychological issues, vulnerability and pain. The psychologist Jung, who suffered serious breakdown, believed that it was a healer's own wounds that made the curative therapeutic journey possible. Wounds, he maintained, potentially bore within them transformative and curative power. Indeed, some believe that a therapist cannot necessarily guide a client anywhere they haven't been themselves.

Of course, this is a complex issue. Those with a history do not necessarily have the wherewithal to be healers, nor are they always ready to contemplate the rigours of clinical practice. Those who bear their own wounds may be terrified of being seen as too vulnerable, and training schemes may be afraid to take on those who confess to significant histories. What if they become a liability? At times I've heard colleagues say that it's okay to confess to a history of mental health problems so long as you were never hospitalised. Ironically, this ludicrous logic reveals that many don’t have much faith in recovery, or indeed the healing power of their own methods. The result is that many of those who could be most valuable to services are either kept out, or kept quiet. The controversial clinical psychologist, Rufus May, confessed to a history of psychosis only once he had qualified. Other wounded healers believe they need to clock up considerable years of practice and a record of reliability before it is 'safe' to reveal their dual status. It is a travesty that those who potentially have the most to contribute are pressured into lives of subterfuge. Arguably, successful transformation of one's own wounds is the highest qualification of all.

Survivors and service-users know this, hence their feelings of betrayal when a wounded healer belatedly 'comes out'. Professionals know it too, despite their collusion with an us-them hierarchy. As a wounded healer myself, I believe aiding others is most potent when practised from a position of common humanity where all are regarded as fellow travellers on this difficult journey of life. This is no easy task, for it requires that we not only gain intimacy with our vulnerabilities, but ceaselessly and courageously confront them. It is the only standpoint that is genuinely authentic in a world in which suffering is inevitable. What we need is an honest appraisal of the issues, so that clinicians like Marsha Linehan and executives like Lisa Rodrigues needn't risk censure when they make known what might be of profound value.

You can follow Angela on Twitter @cyberwhispers.

The IMH Blog is pleased to announce that Professor Paul Crawford's fictional novel Nothing Purple, Nothing Black, is now available in paperback: An intriguing debut novel that deserves a closer look. The lives of two seemingly disparate characters are fascinatingly juxtaposed in this confident debut novel: one is a Roman Catholic bishop on the run from his diocese and the Church; the other, an ex-mental patient on the street, haunted by voices and under the command of sinister beings visible only to him. When the tramp prevents the bishop from catching a train to an uncertain freedom, and offers shelter and a bolt-hole, the pair are set on an inextricable course that can only lead to a tragic climax. With an intricate and masterly narrative, Nothing Purple, Nothing Black casts the reader into a world where the old certainties of order, faith and morality are cast away.

REVIEWS…I really enjoyed it…it is very well plotted…it is humane and somehow tender’ Sara Maitland

'Three bizarre lives become intertwined in this strange and intriguing tale: Harvey, a bishop with carnal yearnings, Crystal, a psychotic tramp, and Olwyn, the object of Harvey's yearning. Cleverly told with some touches of black humour, an unexpected finale and not a moment of boredom - I found it a great read.' Rula Lenska

'Nothing Purple, Nothing Black draws you in and holds you suspended. A psychologically powerful study.' Roy Porter

'Paul Crawford has written with clarity and chastity about the anguish of institutional celibacy…The desperate loneliness of the isolated priest is conveyed with Greene-like insight. A parallel theme is the alienation of the insane… Delusions, hallucinations and compulsions are vividly portrayed. There is no idealisation of the deranged - madness and its expectations are depicted with an insider's knowledge.' Dr Maurice Lipsedge

‘Written with wit and a strong feeling for his protagonists… Crawford’s fictional debut is impressive, and his depiction of the “mad and the sane” sharing “the same bathwater of life” lingers in the mind long after you turn the final page.’ Paul Sayer

‘No other novel explores the painful dilemmas of the vow of chastity as this one does. Anyone who wants to know about the state of the Catholic Church, both from inside and out, must read Nothing Purple, Nothing Black.’ Theodore Dalrymple/Anthony Daniels

'This is a very powerful and touching novel in which the two worlds of the church and the laity are so well portrayed and poetically united. Crawford merges Graham Greene and Patrick Hamilton into the best of both - an obsessive internal landscape set against a murky dusk of a deadly town and a railway station going no-where.' Stephen Lowe

"Nothing Purple Nothing Black is an unusual, and unusually promising first novel. It is an intriguing, topical story, and Paul Crawford tells it with passion, wit and a boldly metaphorical style." David Lodge

The following short film outlines the themes of the exhibition and images from the opening on 6th September 2013 at Djanogly gallery, Nottingham. Featuring curators Victoria Tischler and Esra Plumer.  Throughout the video, Victoria and Esra discuss not only the therapeutic and diagnostic use of art as represented in British asylums, but also how expressions of mental distress have influenced artists and continue to engage us all. Video link: https://vimeo.com/80921476

This was originally blogged here by Dr Rowan Harwood on the British Geriatric Society's blog.  The original blog also contains an excellent video on the BMJ website, which can be accessed here.

 

There is a lot of criticism of how we manage cognitively impaired patients in acute hospitals. And advice on how to do it better. The hope has been that more expert and co-ordinated services would improve outcomes and save resources. But there has been little in the way of rigorous evaluation.

We developed a specialist medical and mental health unit with the ambitious objective of demonstrating best practice. We enhanced the ward environment, ward staffing and skill mix, including mental health specialist nurses, therapists and psychiatry, trained all staff to a high level in the person centred philosophy of care, and endeavoured to engage family carers more fully.

After 18 months of operation we ran a randomised controlled trial, published in the BMJ. This video abstract describes the intervention and trial results.To illustrate the challenges and capture the essence of compassionate person-centred care, we made a 23 minute documentary, called Today is Monday. Footage from this is used to illustrate the abstract.

The full 23-minute film is available for training purposes; interested readers are welcome to discuss this with me This email address is being protected from spambots. You need JavaScript enabled to view it..

 

Dr Harwood is a consultant physician, professor of geriatric medicine at Nottingham University Hospital NHS Trust.

The IMH Blog is pleased to announce that Charley Baker, together with Clare Shaw and Fran Biley have edited a new book on self-harm entitled, Our Encounters with Self-Harm:
This collection brings together a range of voices on the theme of self-harm – from those who have experienced self-harm directly, alongside the friends, family and staff who live and work with self-harm. Too often, our understanding of the unique and complex experiences of people who self-harm is limited to concepts of mental illness, disorder and disease. Yet these stories demonstrate the strength, survival and recovery of people with rich and diverse lives.

Inspiring, hopeful and at times challenging to read, the contributors who have so generously shared their experiences in this book will promote understanding and compassion, improve attitudes and care, and offer hope to those who are personally encountering self-harm. In this respect, this book is of immense value to all those working with self-harm across a spectrum of services and roles, and to those living with self-harm.

REVIEWS:
A courageous and moving collection that challenges every stereotype about self-harm and offers the first real opportunity to understand a complicated and often distressing action as people experience it themselves. If this book were required reading for professionals, it would transform the mental health system. --Gail A. Hornstein, Professor of Psychology and author of Agnes's Jacket: A Psychologist's Search for the Meanings of Madness (PCCS Books, 2012)

A beacon of light. --Louise Pembroke, founder of the National Self Harm Network and editor of Self-harm: Perspectives from Personal Experience (Chipmunka, 2009)

The ‘Our Encounters with…’ series collect together unmediated, unsanitised narratives by service-users, past service-users and carers. These stories of direct experience will be of great benefit to those interested in narrative enquiry, and to those studying and practising in the field of mental health. The series includes "Our Encounters with Madness" ed. Grant, Biley, Walker, and "Our Encounters with Suicide" ed. Grant, Haire, Stone and Biley.

For more information and to purchase a copy of the book, please visit PCCS BOOKS.

The University of Nottingham is justly proud of its links with China. One of its two overseas campuses is at Ningbo, just outside Shanghai. Playing its part in this, the Institute of Mental Health (IMH), where I am based has been building links with China, specifically with contacts in Shanghai, for several years. So when the possibility of a visit arose, I was very keen to join the visiting group.

The main purposes of our visit were to explore the possibility of the IMH contributing to an international centre for mental health in China, that would be able to provide services for expatriates living or working in China, and also to plan the agenda for a high level conference next year to review the operation of the Chinese Mental Health Law, which came into operation earlier this year (translation).

England has had laws around mental health since the 19^th century and the current legal framework can be traced through the 20^th, with significant Mental Health Acts being passed in 1959 and 1983. These have set the framework not just for compulsory admissions but also informal care, the interface between the criminal justice system and mental health, and other issues such as consent. As a result, it is easy not to realise that many countries don’t have such laws, or rely on local regulations for their approach to mental illness. Such was the case in China until 2013. The new law not only sets out the procedure for assessment and compulsory admissions, but it also goes into quite radical territory. For example, it outlaws stigma and discrimination against people with mental disorders, it sets out a responsibility to provide rehabilitation for mental health patients, and it explicitly sets a framework for greater use of psychological treatments and the regulation of practitioners in this area. It was clear from our meetings with psychiatrists in Shanghai that the law will bring about major changes in practice. At least initially, the biggest change may be that compulsory admission can only be used if there is risk of harm to the person or others, so a proportion of patients who were admitted in the past may not choose to accept this now.

Mental health provision is still very hospital orientated and although some facilities are very large – the Shanghai Mental Health Centre has 2000 beds at its two sites – nonetheless the number of beds per capita is lower than the UK. There are relatively small numbers of mental health professionals and these include a larger proportion of doctors than in the UK. An initial appointment would be about 15 minutes on average and the clinics that are held see very large numbers of patients, so medication is generally the only treatment.

The Chinese government is well aware that it needs to change services for mental health. As well as this, China faces extraordinary pressure with an ageing population. The single child policy means that the balance of numbers is tilting rapidly with increasing numbers of old people, who are of course at risk of dementia. This is exacerbated by the pattern of rural to urban migration. Therefore there is much interest in different approaches to care and especially the use of appropriate technology to support older people and their families in the coming years.

It won’t solve the problems of China but during my visit my colleagues and I did manage to submit a grant application for a technology related project. As these things often do, it went to the wire, and the bid was sent with less than two hours to spare. Whew!

Professor Tom Dening Professor of Dementia Research Faculty of Medicine & Health Sciences University of Nottingham

Aiming for good mental health over the long-term is an ambition we all aspire to. The title will seem odd, however, if you are aware that since 2005 chronic disease and chronic illness have been rebranded as long-term conditions (LTC) in UK health policy.

With ageing populations and contemporary lifestyles linked to increased risk of developing chronic disease, finding a sustainable solution for providing good quality healthcare is a global priority. Chronic disease is the world’s largest killer, causing more deaths than any other causes combined (WHO, 2011). By definition they are progressive and incurable, and having one chronic disease raises the risk of developing co-morbidities. It is estimated that between 25-30 percent of people with a chronic disease also suffer from depression, increasing the complexity of treatment options.

The change in terms comes with a change in attitude to chronic disease. It may be treatable but because it’s not yet curable, it is a lifelong condition to be managed. The question of who manages it has also undergone some change, and these days the aim is to get people to take ownership of their illness and to accept responsibility for managing it. Policy guidelines advocating self-management of chronic disease may seem counter-intuitive, unrealistic, even irresponsible, as it seems likely to compromise health if access to formal healthcare services is reduced.

Transitioning to a self-management approach will not be easy. Judging by a recent House of Commons Health Committee on the Management of Long-Term Conditions the current priority is to gain clarity about proposed methods for increasing self-management support. Examples include:

• Integrated health and social care
• Joined up services
• Patient-centred care
• The House of Care

The last bullet-point refers to the ‘house of care’ model (McShane, 2013), which uses a familiar object to communicate the unfamiliar.


At the heart of the house ‘lives’ personalised care planning, with commissioning of services at the base, the coordinated services as the roof, and the opposing walls are made up of engaged, self-managing patients, and supportive healthcare practitioners (Coulter, 2013). The overriding message is that these pieces hang together, but I’m not sure if the metaphor brings us any closer to understanding patient-centred care or how to achieve it.

Undoubtedly the administrative purpose of the Health Committee meeting is to agree on a way forward: once we know what ‘it’ is, we can decide whether we want ‘it’, and whether we can afford to support ‘it’. One of the problems with the current search for clarity is the way it is meant to apply to decisions about programme affordability. Baroness Young, of Diabetes UK, described the difficulty of measuring long-term returns from diabetes patient education.

‘[Patient] education [has] a much longer-term set of payoffs. The barriers of both when and where the payoffs come were to us quite substantial. There were very few that could be realised quite quickly in the same part of the system – that is investors getting the benefit out quickly in the same budget. That, for us, drives very clearly the need for a pooled budget of some sort in order to be able to realise those benefits.’ (Oral Evidence, p 3)
Baroness Young lays blame for the barriers to adopting evidence-based patient education on commissioners’ obsession with neat financial traceability -- cash flowing out of one account to pay for patient education and cash flowing in to the same account from savings due to reduced healthcare utilisation.

She suggests a pooled budget may be the solution. Would such a change improve the current decision-making model’s myopia? Would it be better at measuring longer-term benefits, or attributing positive spillover effects to the relevant programmes? An example of spillover is improvements in the quality of care provided by healthcare practitioners as a result of patient education provision.

This was one of the findings from an ESRC-funded study (Go Jefferies, 2012) that explored the extent that healthcare practitioners accepted the self-management approach to diabetes care. The study found that healthcare practitioners delivering the 6-week X-PERT Programme to patients had unexpected benefits.

Healthcare practitioners who are also qualified self-management Educators (n=11) suggest that the training to become a qualified X-PERT Educator surprised them by how little they knew about diabetes care, and provided them with important new knowledge and skills outside of their normal specialism. The X-PERT based knowledge and skills were also perceived to improve their support of diabetes patients in their regular clinical roles through adoption of the X-PERT approach and educational materials to regular clinical practice. This increased access to X-PERT principles to those patients who did not attend the full programme.

The Educators expressed satisfaction not only in being more effective at communicating complex diabetes information to patients in a logical way, and which allowed patients the time they needed for the ‘mists [to clear]’ about what diabetes is. Participants also expressed relief from professional anxiety about shifting responsibility for diabetes care onto patients because they were able to have more sophisticated conversations with post-X-PERT patients, as they believed patients were more able to make informed decisions about personal care plans.

Furthermore, the study showed that because delivering X-PERT to Type 2 diabetes patients at diagnosis is a deviation from standard diabetes care pathways, the delivery of up-to-date knowledge and advice before the onset of complications was seen as reducing patients’ exposure to potentially harmful poor advice that participants assumed came from non-diabetes specialists in patients’ regular primary care teams. Recognition of improvements to their own diabetes understanding had positive effects on Educators’ perceived professional effectiveness to help patients according to best practice.

Employee satisfaction has spillover effects on customer interactions  (Bowen et al., 1999). Such spillover effects are evident as positive mental health effects perceived by healthcare practitioners who deliver self-management training programmes to patients. Therefore the good mental health of healthcare practitioners is likely to have positive effects on patient interactions.

 
[caption id="attachment_1201" align="aligncenter" width="212"] How is self-management becoming institutionalised? - Poster by Go Jefferies, Hibbert and McDonald (2013)


 
Josephine Go Jefferies (This email address is being protected from spambots. You need JavaScript enabled to view it.) is an ESRC Doctoral Researcher at Nottingham University Business School (Marketing Division) at the University of Nottingham. She is currently studying patient experiences of telehealth for the self-management of chronic disease.

Open source software refers to software whose code is available for anybody to view, revise and reuse. This should be contrasted with closed or proprietary code which is known only to the manufacturer, and who will often charge a fee for individuals to use the software (for example, Microsoft Word, or Adobe Photoshop).

There are many types of open source licence but the principle of viewing, revising, and reusing underpins them all. On the face of it, this does not seem like a very exciting proposition, and newcomers to the concept often wonder what difference such an apparently obscure part of software licensing could make.

However, because open source software (often, although not always, available at no cost, and referred to as Free and Open Source Software or FOSS) can be modified by anybody it offers a number of advantages over traditional proprietary software.

Firstly, FOSS is free. I'm writing this blog post on a computer which contains absolutely no software of any kind that costs any money whatsoever. I shall repost it on my self-hosted blog which runs on a server which itself contains no software of any kind that costs any money whatsover. In a time of austerity, the availability of free software that can perform all the tasks of paid software should be a deafening clarion call across the public sector. And indeed FOSS is starting eto gain traction in education and health.

However, not only this, but FOSS is often better than its paid counterpart. This is because anybody can change and improve it, and whole communities exist around popular tools, adding new features and fixing bugs continuously with everyone inside and outside of the community benefiting. The FOSS operating system Linux basically runs the internet. The closed source Microsoft Excel, notoriously, features bugs that Microsoft can't or won't fix (e.g. here and here). Even the US Military are making ever larger use of open source software.

The statistical programming language R is another success story from the FOSS world. Precisely because it is free and open source, a huge community of statisticians, programmers, data visualisers and analysts all contribute to its development. At the time of writing there are nearly 5000 user contributed packages within R, which help users with tasks as diverse as computational chemistry and physics, finance, clinical trials, medical imaging, psychometrics, machine learning, statistical methods, and the production of extremely powerful and flexible statistical graphics. R is rapidly becoming the lingua franca of analytics and is widely used in many leading  data science departments, perhaps most notably Google.

I have made extensive use of R in my work on Nottinghamshire Healthcare NHS Trust's new patient feedback site, using R to serve both static quarterly reports as well as interactive, searchable analysis of all of our feedback past and present.

The searchable reports are made possible by the Shiny package which makes it ridiculously easy to allow users to interact with a dataset. Shiny handles all of the hard work involved in programming a graphical user interface and lets analysts such as myself concentrate on the content of what is delivered to the user.

Although Shiny is never going to replace other methods of programming for very large, fully featured analytics platforms (for example, Google Analytics) it has certainly proved its worth on the patient feedback website and I would hope that R and Shiny would find more and more use in NHS settings up and down the country to allow Trusts to better communicate their data to the communities and service users whom they serve.

I have written a book about Shiny which can be found here. The book is designed to be read by individuals new to the R language, and includes lots of examples using R/ Shiny as well as HTML, CSS, JavaScript and jQuery that show how Shiny can be best utilised and extended to produce attractive and powerful interactive analysis applications.

There are some demonstrations of what can be done with Shiny on my website, some are little examples I wrote just for the book but some are more fully featured than that and hopefully demonstrate some of the things which can be achieved using Shiny.

Over the next 10 years I hope to see more and more use of FOSS, not only for the Free, but also for the Awesome.

Posted by:

Chris Beeley, PhD, C.Psychol

Senior evaluation manager & Honorary lecturer, School of sociology and social policy

Institute of Mental Health, Nottinghamshire Healthcare NHS Trust

Originally posted on The Mental Health Elf on 7 November 2013.  Herbal medicines often represent a cheaper alternative, or a low-cost complement, to standard pharmacotherapy. As a result, improved cost-effectiveness is often touted as a likely benefit of the use of complementary and alternative medicine (CAM).

Many, myself included, have been openly critical of CAM research,Herbal medicines often represent a cheaper alternative, or a low-cost complement, to standard pharmacotherapy. As a result, improved cost-effectiveness is often touted as a likely benefit of the use of complementary and alternative medicine (CAM).

Many, myself included, have been openly critical of CAM research, while others have suggested ways in which CAM research could be improved. As with studies of efficacy and effectiveness, there is a lack of good quality evidence regarding the cost-effectiveness of CAM-based interventions.

St. John’s wort (SJW) is a herbal medicine, most widely associated with the treatment of depression. Millions use it in the UK. A Cochrane review of its use for major depression has found it to be superior to placebo (Linde et al, 2008); a credential that few CAM treatments can claim. However, there remains a lack of evidence regarding the cost-effectiveness of the intervention.

A recent study by Solomon, Adams and Graves, published in the Journal of Affective Disorders (Solomon et al, 2013), attempts to begin filling the gap. We thought it well worth the elves having a look at this study and exploring the cost-effectiveness of St. John’s wort for the treatment of depression.

Methods

[caption id="" align="alignright" width="294"] Fig. 1. Markov model of transmission between states. (© Elsevier)


The study carries out a model-based economic evaluation of St. John’s wort compared with antidepressants for the treatment of acute mild to moderate depression. This approach synthesises data from different sources to answer questions about cost-effectiveness that have not previously been answered by prospective trials.

The study employs a Markov model, which requires that patients can be defined as being in one of a finite number of ‘states’, and that the probability of transition from one state to another is constant across all individuals within that state, regardless of their history. In this study the authors define 3 possible health states – depressive episode, response and remission – as shown in Fig. 1.

The model evaluates 3 possible courses of treatment; SJW, venlafaxine or sertraline. Each of these is associated with different probabilities of transition between the depression states and different costs.

The cost of SJW, venlafaxine and sertraline is 0.70, 1.35 and 0.75 $AUS per day respectively, and costs are estimated from the perspective of the national health provider.

The primary outcome is quality adjusted life years (QALYs), which are defined by the model states and are assumed constant across the treatment arms. The comparative benefit of treatment is defined by response rates, remission rates, relapse rates and adverse effects.

Results

Results indicate that SJW dominates – that is to say is cheaper and more effective than – antidepressants. Having carried out a probabilistic sensitivity analysis the authors assert that:

'The decision maker can select SJW as the preferred or alternative treatment option with a high degree of confidence…'

Limitations

[caption id="" align="alignright" width="300"] It isn’t clear whether or not the study used data from comparable populations


Though the study is reasonably well reported it has a number of limitations.

• It’s possible that the study used some inappropriate data for its parameters. For example, response rates for venlafaxine are taken from a review including patients with mainly severe major depression, while the response rate for SJW appears to be based on an unpublished meta-analysis.
• Some assumptions also work in favour of SJW. For example, patients that discontinue then recommence treatment are assumed to require extended consultations with their GP, increasing the incremental cost of antidepressants.
• The design of the model also appears to be flawed. Individuals are allowed to ‘leave’ the model, in which case they become unobserved, and this could significantly bias the results.
• Furthermore, the model does not consider all possible treatment options. If we take a look at the NICE guidelines for depression, for example, we’ll see important roles for psychotherapy and cognitive behavioural therapy, as well as many alternative SSRIs and other classes of antidepressants. NICE guidelines do not explicitly recommend venlafaxine or sertraline.
• It’s also worth mentioning that the study received funding from the Complementary Healthcare Council of Australia.

Discussion

[caption id="" align="alignright" width="200"] While it’s clear that the direct costs of SJW are lower, any indirect costs or savings to the health service remain unknown


Unfortunately this study is unable to identify, with any confidence, the likely incremental cost differences associated with the use of SJW. This is due in large part to the availability of data; the predictive validity of a model is wholly dependent on the availability of good data. While we know that the direct cost of SJW is lower than that for traditional antidepressants, there are no data available regarding the possible indirect costs of SJW. As such, the model must depend on inferences and assumptions about service use. These questions can only be answered by a prospective trial-based cost-effectiveness analysis.

It is reasonable to expect that the model used in this study, employing different assumptions, could produce entirely contradictory results. This is because the model is not comprehensive. Not only are there many other antidepressants aside from the two considered here, and non-pharmaceutical therapies, but there is also a wide array of SJW products. There are also many other relevant service use parameters that could have been included, such as inpatient care or contacts with community mental health teams, which could substantially alter the results.

Though no model can ever be definitive or entirely depended upon for policy decisions, there remains scope for a more comprehensive modelling study of the cost-effectiveness of SJW compared with alternative lines of treatment. Such a model would be greatly enhanced by a prospective trial of the cost-effectiveness of SJW, which could thoroughly capture the direct and indirect costs of treatment. Hopefully this is something on which the elves can report in the future.

Links

Solomon, D., Adams, J. and Graves, N. Economic evaluation of St. John’s wort (Hypericum perforatum) for the treatment of mild to moderate depression. Journal of Affective Disorders 2013; 148: 228-234. [PubMed]

Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD000448. DOI: 10.1002/14651858.CD000448.pub3.

Depression in adults. NICE Clinical Guideline 90. National Institute for Health and Clinical Excellence, 2009.

Sampson, C.J., Whitehurst, D.G. and Street, A. Do patients registered with CAM-trained GPs really use fewer health care resources and live longer? A response to Kooreman and Baars. The European Journal of Health Economics 2013; 14(4): 703-705. [PubMed] [RePEc]

Solomon, D., Ford, E., Adams, J. and Graves, N. Potential of St John’s Wort for the treatment of depression: the economic perspective. Australian and New Zealand Journal of Psychiatry 2011; 45(2): 123-130. [PubMed]

Tomes, C. CAM: Many of us are using it, despite poor evidence. Whats going on? The Mental Elf, 10 Oct 2013.

'Art in the Asylum: creativity and the evolution of psychiatry’, is curated by Dr Victoria Tischler and Dr Esra Plumer, and presented in the Djanogly Art Gallery, Lakeside Arts Centre, University Park until the 7^th November. This exhibition is a richly rewarding experience on two levels. Firstly, the viewer is offered each work in its own particular chronological and spatial context. The exhibition includes a diverse range of material, including pieces from artists whose work is produced within the influence of continental psychiatry and work representing the earliest asylum art from Scottish institutions. As this exhibition unfolds in front of us, we are witnessing the evolution of over 100 years of artistic activity in British psychiatric institutions, spanning  from the 1800s to the 1970s.

But the exhibition is an enriching experience on another level. Woven into the historical and comparative narrative are the voices of each individual artist. As you walk through the exhibition space, you become aware of the clamouring of these voices.  Voices which, paradoxically, can only truly make their experience understood through visual means. The content of each piece is part of an intensely personal journey made by an individual struggling to maintain, or explore, their sense of identity in the face of mental illness.  Much of this work is locked to this internal focus; the artist is overwhelmed by the need to relate an internalized experience. But for some of the artist-inmates the opportunity to ‘make’ art in the asylum is an opportunity to become political, to set their experience in a socio-political framework.

One work which uses this socio-political framework is ‘I spit on Life’ by William Kurelek.

[caption id="attachment_1165" align="aligncenter" width="500"] William Kurelek. I spit on life. Courtesy of Adamson Collection, (c) Kurelek estate, Wynick/Tuck gallery.


In creating ‘I Spit on Life’ , the poster image for this exhibition,  William Kurelek shows us, in a powerful series of illustrative vignettes,  that the inmates of our asylums, the recipients of our ‘care’,  can  take the initiative in the dialogue between the ‘individual ’ and the ‘system’.  My own research is particularly concerned with the changing relationship between the client and the expert practitioner within the social institutions of education and health. I am exploring the possibility that in our post industrial world the locus of authority is shifting from the practitioner, the system, to the client, the individual. For me, Kurelek’s work is not only important for its expression of his personal experience but in the way it makes explicit that, in the words of Shulamith Firestone: ‘the personal is political’.  Kurelek  describes his experiences not only for us to comprehend his personal distress but for us to regard, and to judge,  the ‘political’, the ‘system’, in action.

There is a theatrical  and dynamic sense about Kurelek’s work which transforms us from passive viewers into an engaged audience. Among the series of vignettes which make up this work there are two  which I find are particularly powerful representations of this effect. They concern his experiences in the institutions of education and of health. In Image 2, Hospital, the patient is receiving a lecture from a psychiatrist. We see the unconcerned nurse, sitting in an almost languid pose on the coffin lid, but using her body weight to push it down on the patient while the psychiatrist, seemingly without any reaction to the horrific scene in front of him, continues to expound some theory, or perhaps offer some advice.  We suspect that the psychiatrist’s theories and his advice are not relevant to the man peeping out in horror from his institutional coffin. The lid is about to close and we feel the urge to step in, lift the lid and free the man trapped underneath it. The action we would bring to this scene is based on our common humanity, a sense of outrage at what is happening.  Kurelek cleverly  engages our sympathies with the terrified  ‘patient’, who is the only figure in this vignette showing  a ‘normal’ emotional response to the event. By default, those showing no emotion, the institutionalised professionals, must be the abnormal ones.

[caption id="attachment_1162" align="aligncenter" width="300"] William Kurelek. I spit on life. Image 2. Hospital. Courtesy of Adamson Collection, (c) Kurelek estate, Wynick/Tuck gallery.


Thus Kurelek persuades us of the efficacy of his argument; institutions desensitize individual practitioners until they no longer respond with recognizable humanity in the face of the suffering of their ‘clients’.  This, of course, is the very argument that has led the political debate in the last few years over the training and behaviour of our expert practitioners in Health and Education.

The student cramming knowledge in a library (Image 4 Student Days), gives an equally damning picture of the institution of higher education. The student is alone, holding his head in his hands, and behind him stretches a vast empty corridor of books. We sense his desperation. He must learn, and learn at the pace dictated by the institution, some examination of which he is taking.  He seems to find no pleasure in learning.  The implication is that he is on his own, unsupported by the institutionalized professionals whose job it is to ‘teach’, to ‘lead’, to ‘guide’, him to academic success.

[caption id="attachment_1163" align="aligncenter" width="300"] William Kurelek. I spit on life. Image 4 Student Days. Image Courtesy of Adamson Collection, (c) Kurelek estate, Wynick/Tuck gallery.


Again, Kurelek is directing his anger at the ‘professionals’, the ‘expert practitioners’, who fail to fulfill their contract of public service.

But, as I reflect on my research interviews with over forty expert practitioners in Health and Education, and while accepting that we are in what has been described as a ‘crisis of service’, I find my sympathies lie as much with these expert practitioners as with their clients.  These practitioners are the  ‘professional class’, described by Perkin (1989) as having an ethos of service, a respect for properly adjudged qualifications and a desire to work effectively within the pursuit and use of their knowledge. As I listen to my audio transcripts I hear expert practitioners tell me that these principles are under increasing threat from a devaluing of the centrality of their expertise to the successful delivery of our ‘Public Services’.

Expertise relies upon a basis of what Frank Webster (2006) called ‘theoretical knowledge… formalized in texts and transmitted through the educational process’.  At the 2013 Kaleidoscope Conference in Cambridge, Stephen Ball, in reference to ‘theoretical knowledge’  spoke of the fundamental ‘job of academia’; to tell the truth.  He described the effect of ESRC Impact guidelines, positing that research could no longer be seen to be an end in itself, and implying that researchers were no longer free to ‘search after the truth’.

In support of that argument, it is suggested that, in university education,  with the introduction of the REF ‘there is a new shift from accountability over finances to control over substance and the content of what is researched’ (Olssen 2011).

What effect does this shift of control away from the expert practitioners have on their experience of daily professional life? A Cardiff University study by Smith, Collins, Matthews and McNamara (1993) into workplace stress commissioned by the Health and Safety Executive found that, apart from bureaucratic overload and a general lack of time to complete tasks…  ‘there are anecdotal reports from professionals ….. that uncertainty due to the changing nature of work, may be related to the increases in perceived stress.’

After reading this, I look again at the psychiatrist in Image 2.  Is he suffering from burnout? Is that passive face the expression of a man with low affect? Is he depressed? We have to ask again, although with a perceptibly altered perspective from that of Kurelek- is indeed the psychiatric patient the healthiest person in this image?

[caption id="attachment_1164" align="aligncenter" width="274"] Work chosen: William Kurelek. I spit on life. Image 2 Hospital. Courtesy of Adamson Collection, (c) Kurelek estate, Wynick/Tuck gallery.


Perhaps Kurelek’s powerful depiction of the ghastly failings of organized society to recognise the vulnerability of the individual could extend its franchise to include the expert practitioners who are caught up in these devalued ‘services’?

Processes such as the collection of both qualitative and quantitative data  on client responses to Health and Education through  ‘student voice’ and ‘patient feedback’ demonstrate the increasing governmental emphasis on the importance of ‘client critique’ to assess practitioners. This client critique could extend out from its narrow focus on the perceived failings of individuals within the public services to encompass both an informed critique of the actual structure of these services and an understanding of the implication of constant change for the expert practitioner. Extending the remit of ‘client critique’ in this way could contribute to a powerful partnership between the practitioner and the informed client. The lobbying power of such a partnership would be a political force with which to be reckoned.

I ask you to look back at the dark images of ‘I spit on life’ for a moment and imagine Kurelek’s images reformed into a network of such successful partnerships.  Not a glossy public relations exercise in imaging the promised land but a real depiction of a functioning  set of services embedded in, and supported by, the society which it serves.  Something which works.

To paraphrase Mrs Doyle,’Ach, come on.  Sure, we know we want it.’

The question is - how to get it?

Writer: Fiona Birkbeck  PhD Title:  The Cry for Professional Intimacy.  Changing relationships between the expert and the client in the post industrial landscape of our health and education services. Email:  This email address is being protected from spambots. You need JavaScript enabled to view it.
References:
Ball, Stephen. (2013) Kaleidoscope Conference, Cambridge

Firestone, Shulamith. (2003) The Dialectic of Sex: The Case for the Feminist Revolution

Olssen, M. (2011) The strange death of the liberal university: research assessment and the the impact of research’, in R,King, S Marginson and R Naidoo (eds) A handbook of globalisation and higher education, Cheltenham: Edward Elgar

Perkin, Harold.  (1990) The Rise of Professional Society: Britain since 1880 Routledge

Smith, A., Brice, C., Collins, A., Matthews, V., and McNamara, R.  (1993) The Scale of occupational stress: A further analysis of the impact of demographic factors and type of job Centre for Occupational and Health Psychology, Cardiff University for the Health and Safety Executive

Webster, Frank.  (2006) Theories of the Information Society  Routledge

While nursing my disappointment that I’d missed the talk that inspired last week’s blog, “People Who Heal Us: the role of peer support in mental healthcare treatment”, I found myself dwelling on the question posed by Jenelle Clarke. Was it “the principles of CBT or the peer support that had been the most helpful in overcoming social anxiety”?  I was reminded of an article I read recently, entitled:   ‘Water clubs in residential care: Is it the water or the club that enhances health and well-being?’ (Gleibs et al., 2011). This study explored whether the reported benefits of water club membership led to enhanced perceptions of wellbeing due to a reduction in the negative effects of dehydration or the increased social engagement. Interestingly, the beneficial effects of water were only found when delivered in the context of a club, as opposed to in an individual intervention. Social support had a positive effect on quality of life and, intriguingly, it was identification with other club members that mediated this effect.

Warnings against the spiralling consequences of our individualistic society are all too familiar and it is now well established that lack of social contact can have detrimental effects on both physical and mental health. The additional contribution made by the water club study was to propose identity processes as an underlying mechanism. There has been a burgeoning interest in the social identity approach to health in recent years, but, returning to Jenelle’s question, what are the implications for the realm of mental health research and practice?

Perhaps the additional factor in the context of mental health is that of stigma, topically discussed in Amanda Keeling’s IMH blog earlier this month, “Fear and Loathing: Combating the Stigma Against ‘Scary’ Disorders”. If identification with fellow group members indeed underlies the benefits of peer support, what happens when those identities are stigmatised? Much has been done to raise awareness of the barriers to social integration created by stigma and considerable research now documents prejudices against those living with mental health difficulties. Apparently less attention has delved in any detail into the ways identification with stigmatised groups influence recovery.

A notable exception is research by Crabtree and colleagues (Crabtree et al., 2010). This explored self-perceptions of stigma and the implications of identification with a stigmatised group.  According to social identity theory, group membership plays a key role in determining self-esteem (Tajfel & Turner, 1979). Since intergroup comparisons are relative, membership of a stigmatised group has the potential to adversely impact self-esteem.Clearly this has implications for engagement with both clinician-led and peer support groups.  However, the researchers found that the shared identity of stigmatised group members provided the support needed to resist stigma, challenge prejudice and provide a buffer against the negative effect of discrimination. There was a darker side to this finding, though; the protective mechanisms positively affected self-esteem, but simultaneously supressed a negative relationship between self-esteem and social identification.  Underneath the protection afforded, the more individuals identified with their mental health support group, the worse they felt about themselves (Crabtree et al., 2010).

I’m the first to advocate the importance of community and social support and to lament the rise of an individualistic culture. We exist in relationship with one another. Nevertheless, such research does point to the complexities of group dynamics and the need for caution when presenting the mere existence of support groups as a route to improved wellbeing.  How such groups are viewed by participants and the impact of belonging to them needs to be considered, particularly if membership does not alsoprovide increased social support.  Perhaps part of the problem is where our primary identity lies and the tendency to see diagnostic labels as part of an individual’s essential identity. As Amanda pointed out in her blog, “people with mental health problems are people first and foremost”. This makes the fight against stigma all the more urgent. If their fundamental identity and value is secure, more people may avail themselves of the potential benefits of therapeutic groups rather than avoiding the opportunity due to the connotations being part of such a group may confer.

References:
Crabtree, J., Haslam, S. A., Postmes, T., & Haslam, C. (2010) Mental health support groups, stigma, and self-esteem: positive and negative implications of group identification. Journal of social issues. 66 (3), pp. 553-569
Gleibs, I.H., Haslam, C., Haslam, S.A., & Jones, J. (2011). Water clubs in residential care: Is it the water or the club that enhances health and well-being? Psychology and Health, 26, 1361-1378.
Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin &
S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33 – 47). Monterey, CA:
Brooks/Cole.

Kathryn Smale, ESRC PhD student, School of Medicine
This email address is being protected from spambots. You need JavaScript enabled to view it.

As part of the Art in the Asylum exhibition currently underway at Lakeside, I recently attended the Ancient and Modern Mental Healthcare lecture held on 2 October 2013.  Speaking at the lecture were Jules Evans with Dr Arun Chopra and Dr Ben Di Mambro.  All three speakers focused on different aspects of mental healthcare treatment as depicted from Greek philosophy, films, politics and popular culture.  Rather than give a summary of the evening, I would like to instead highlight the question I have been mulling over following the lecture, namely the use of peer support as a treatment for mental distress.

The ideas of peer support started off with Jules Evans giving us an overview of Cognitive Behavioral Therapy (CBT) and explained how it derives from Greek philosophy, particularly stoicism.  His talk was centered on his own personal story of mental health difficulties in his early 20’s as a result of drug use and his recovery from social anxiety through the use of CBT.  Interestingly, rather than the traditional CBT model of individual therapy with a mental health professional, Jules received help from a peer support group that used a computerised CBT course.  There were no clinical practitioners or mental health professionals – just others who also struggled with anxiety helping each other.  This raised the question for me as to whether it was the principles of CBT or the peer support that had been the most helpful in overcoming social anxiety.  Furthermore, in terms of the peer support, what was it specifically that was beneficial?

The importance of peer support in a therapeutic process is not a new concept, least of all in mental health research.  Many others (Lapsley et al., 2002; Corrigan and Phelan, 2004; Hogan et al., 2002; Davidson et al., 1999; Haigh, 2005; Pilgrim et al., 2009) have done an admirable job of highlighting the use and benefits of peer support.  But it does raise some important questions when exploring the use of peer support as a form treatment, either on its own, or in conjunction with another form of therapy.  What mechanisms are actually at work that make it ‘effective’?  What happens when it goes wrong?  What about the role of power, social control, peer pressure and marginalising?  We (and I definitely include myself in this!) often use sweeping statements, such as relationships are central within mental health treatment.  But as I unpack that I am constantly asking myself – what does that actually mean?  What are we saying matters most?  Contact with people?  Contact with certain types of people?  What types?  And so on and so forth…

My point is that as a form of treatment, peer support is not a routinised model of care in the same way as CBT.  Thank goodness!  Yet it does mean that as a mechanism of change, it receives far less scrutiny.  In addition, much of the social support research focuses on the outcomes of support and does not explore the processes at work within these interactions.  For instance Corrigan and Phelan (2004:519) in their study of individuals with a diagnosis of mental illness found that whilst social support seemed to reduce distress symptoms, it is unclear ‘how social support promotes symptom remission’.

As a form of mental healthcare treatment, peer support can play a vital role in recovery.  After all, the old adage carries a lot of truth: it is people who hurt us and people who heal us.  Yet as Haigh (2005) notes, our question should not be so much do the relationships work and is personal change achieved, but rather what do these relationships and interactions actually mean, how are these meanings constructed and how do they play a role in transformative change.  Questioning, challenging and extending our knowledge of peer support is necessary as, for many people, it forms such an important part of personal change.

Jenelle Clarke, ESRC PhD student, School of Sociology and Social Policy, This email address is being protected from spambots. You need JavaScript enabled to view it.
References:
Corrigan, P.W. and Phelan, S.M. (2004) Social Support and Recovery in People with Serious Mental Illnesses.   Community Mental Health Journal 40(6): pp.513-523.

Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D. and Kraemer Tebes, J. (1999) Peer Support Among Individuals With Severe Mental Illness: a review of the evidence. Clinical Psychology: Science and Practice 6(2): pp.165-187.

Haigh, R. (2005) The Trouble with Modernisation: we need better relationships, not policies and procedures. Mental Health Review Journal 10(3): pp.3-7.

Lapsley, H., Nikora, L.W. and Black, R. (2002) "Kia Mauri Tau!" Narratives of Recovery from Disabling Mental Health Problems. Report of the University of Waikato Mental Health Narratives Project. Wellington: Mental Health Commission.

Pilgrim, D., Rogers, A. and Bentall, R. (2009) The Centrality of Personal Relationships in the Creation and Amelioration Mental Health Problems: the current interdisciplinary case. Health: an interdisciplinary journal for the social study of health, illness and medicine13(2): pp.235-254.

(originally posted on the UoN Blog on 17 October 2013)

Why is a leading psychiatrist concerned about not having the resources needed to provide psychiatric care?  Martin Baggaley, South London and Maudsley’s clinical director hit the headlines this week when he stated that too many psychiatric beds had been closed.  It is possible to specify fairly precisely how many beds are sufficient to meet the needs of people with severe mental illness.  After all, the prevalence of mental disorders can be estimated within reasonable parameters, based on nationally representative surveys and mental health services have masses of data about readmission rates and co-morbidity, and clinical commissioning groups should have this information. In fact it is not bed numbers, but the balance of community and hospital provision that is at issue here, and data collated for a European study led by the Institute of Mental Health, Nottingham throw light on this balance.

The UK is a world leader in community care. Whereas some other countries, including Belgium and Malta, rely almost entirely on psychiatric hospitals to provide mental health care, for half a century in the UK we have had a strong bias against hospital admission because of its associated stigma, costs and the risk of institutionalisation that long-term admissions are believed to pose.   Responsive, community-based services were developed to span all levels of complexity, from early intervention in psychosis to home treatment for people in crisis.  These comprehensive services have been adversely affected by the cost improvement plans imposed on all providers.  It’s easy to count beds and I don’t disagree that the numbers have been sharply reduced in recent years.  However, as Martin Baggaley states, the shortage of beds is part of a general reduction in mental health and social care provision, it’s one of a swathe of so-called ‘cost improvements’.

Given the recent history of mental health services, it is not surprising that, of 29 European countries, the UK has the ninth lowest number of psychiatric beds per capita.  But it is remarkable that, according to WHO European Hospital Morbidity Database (2012), people admitted to hospital in the UK with schizophrenia (for instance) on average spend nearly four months as inpatients – twice as long as most other countries in Europe.  We need to understand more about these long-term hospital admissions and why the limited inpatient resource seems to have an exceptionally low throughput.

This is a guest blog by Professor Justine Schneider (pictured above), an expert in mental health service evaluation and dementia care in the University’s School of Sociology and Social Policy. This blog draws on a new report ‘Mental health Systems in the European Union Member States, Status of Mental Health in Populations and Benefits to be Expected from Investments into Mental Health’ by Chiara Samele, Stuart Frew and Norman Urquia, 2013.

By something as a way of a general disclaimer, I will say that this is something of a stream of consciousness, based simply on my own impressions as a member of the public.  By all means feel free to criticise roundly what I've said in the comments below.

A decade ago, the Richardson Committee presented their report to the Government recommending a complete overhaul of the English mental health legal framework (pdf).  It was highly progressive, recommending a rights-based framework with an emphasis on patient involvement and autonomy, putting the individual at the heart of the system.  It aimed to combat stigma and social exclusion, and recognised that people with mental health problems are people first and foremost.  Alas, it was not to be.  The Labour government, driven in a large part by the public, dismissed the proposals, and made it clear that their preoccupation for legal reform was the risk people with mental health problems apparently posed to the general public.  It appears very little has changed.

 The University of Manchester recently released a report (pdf) into figures for suicide and homicide amongst people with mental health problems.  Though passed by in most of the media, preoccupied with the sale of Royal Mail, the Sun thought it fit to report it thus:

 

The issues with this headline are almost too many to list (thought the Independent and the Guardian both do an admirable job).  Most obviously, it is sensationalist, and reports only half of the report, choosing to focus only on the homicides than the suicide rate – which, as Time for Change note, is sadly a much bigger risk to people with psychosocial disabilities; 90% of suicides in the UK are by people with mental health problems.  The debacle of the ASDA 'mental patient' halloween costume, and similar offerings from Tesco's and Amazon, demonstrates that there is still an underlying fear that people with psychosocial disabilities are likely to turn into ‘mad axe murders’ at any given second, and The Sun’s headline does absolutely nothing to dispel this belief, even if the actual article itself was more nuanced and suggested that it was the system that had failed, rather than the individuals themselves being inherently dangerous (though I’m not sure that I’d want to see their ideas of an improved system).  When a 3rd of the population believe that people with mental health problems are likely to be violent, when in actual people with mental health problems account for only 5% of homicides, this kind of reporting is completely irresponsible.

However, in the aftermath of the ASDA debacle, I noticed something that I found slightly troubling.  I can’t claim to have done a rigorous search on this, so this is simply my impression of what I have seen as a member of the public, not as a mental health researcher, but the prominent responses were primiarily from people who had depression.  Rightly, they were angry at being characterised as 'mad axe murderers' - but I couldn't help thinking that, actually, they were not being characterised as so.  While it would be wrong to say there is no stigma around depression, and that we are all open and understanding about it, it is not depression that the general public think of when they think of ‘mad axe murderer’, or the stereotyped mental patient in strait jackets and padded cells.  Depression is not 'madness' in the eyes of the general public: it is psychosis, and personality disorders, and it is this group who are damaged by those costumes, and the Sun's reporting.

However, it is not this group who have been targeted in the campaigning.  The prominent celebrity voices, working hard to normalise mental illness have been Ruby Wax, Stephen Fry, and Alistair Campbell, all who have experienced, or continue to experience, some kind of affect disorders.  Where is the voice for psychosis, or personality disorder?  The latter is still associated with the cold, heartless killers so popular in our detective TV shows, the former perhaps most closely correlated with ‘madness’.  These are seen as unpredictable, ‘scary’ disorders, and it is these which people most closely associate with the ‘psycho killer’ headlines of old, and which were most closely targeted by the ‘mental patient’ costumes, and the Sun headline this week – not depression.  Despite this, however, the voice of these individuals is less prominent.  Wikipedia lists a number of celebrities who are said to have/have had schizophrenia, yet none of them has the same profile as Wax, Fry or Campbell in terms of advocacy for normalisation and open dialogue for the disorder.  The reporting of Stephen Fry’s account of his attempted suicide was, in the main, done sensitively and commended; in contrast, Amanda Byne’s increasingly erratic behaviour has been documented salaciously, in a manner reminiscent of Britney Spears’; her diagnosis with schizophrenia has been greeted with sympathy, but the run up to her committal in a secure facility was covered with both a tone of incredulity and wariness.

The national media has a lot to answer for in terms of how it reports stories around the ‘dangerousness’ of people with mental health problems – but equally the focus on ‘safe’ disorders from campaigns is perhaps missing an important point.  People do not fear people with depression - they fear depression itself, and the campaigns have done a remarkable job opening dialogue and normalising depression.  Now, we need to do the same work with other disorders; fear only goes away with greater understanding, and a greater public discourse around fear of the perceived 'danger' of people with mental health problems to others needs to begin.

Amanda Keeling, PhD Student, School of Law, University of Nottingham, This email address is being protected from spambots. You need JavaScript enabled to view it.

“What a sad era when it is easier to smash an atom than a prejudice.”
― Albert Einstein

I was recently sent a ‘humorous’ email called the ‘Alberta Mental Health Release Examination’, forwarded as a group email to everyone on a University mailing list for, presumably, light relief. Please have a go at completing it yourself:

Test

Results

 
Now, it isn’t clear from the Form whether we are reading a knowing satire on the absurdities of (presumably) arcane psychiatric practices, or the piece is trading on a social stereotype equating mental health difficulties with a lack of intelligence and/or a chronic lack of common sense (Common Sense Deficit Disorder – or CSDD - in the new DSM-V anyone?). If the former, it is rank prejudice of a type that would be considered entirely and rightly unacceptable if, for example, it was aimed at gender or ethnicity; at best, it is very close to the mark. Either way, the fact that such an email can be sent on a group list, without any awareness that the content may be considered inappropriate, tells us a lot about what is, or what is not, considered offensive in our society today.

It’s probably too much of an easy target to use the Conservative Party Conference as an example of unthinking prejudice, but as the remarks in question involve the current Minister for Health, I think we can make an exception here. During his speech, Jeremy Hunt made two rather inappropriate ‘jokes’: the first was about having a seizure (funny topic that), the second about how some people think he needs an operation for his head. Whilst I’m sure many of us would agree that there are certain aspects of Mr Hunt’s intellectual credibility that require closer examination (his association with Rupert Murdoch for one) I consider it quite remarkable that such a senior politician could make light of such serious issues, in such a high profile way. I’m sure Mr Hunt meant no offensive by his remarks, and would probably be shocked if he realised how they have been received by some people. However, it’s the fact that he can make such statements unknowingly, and that they can go relatively unnoticed in the national press, which to me highlights how certain (negative) attitudes towards mental health difficulties have become a cultural norm.

If the Alberta Mental Health Release Examination Form and Jeremy Hunt’s comments were close to the line, then Tesco and Asda blundered over same line in spectacular fashion (think rabid bull on steroids bushwhacking its way across a field). Now I’m sure most people reading this article would have already seen these images, but for those of you who have not seen the ‘Mental Health Patient’ Halloween costume, have a look at this:


I’m not sure whether it’s the blood-splattered straitjacket, the macabre mask or the meat-cleaver which I find most offensive; all in all, it adds up to one large, sorry mess. The fact that this costume must have passed several chains of command to reach the shop front is astonishing.

Thankfully Asda and Tesco have apologised for the costume and removed it from their stores, which I guess is a cause for hope. As the Centre for Mental Health Blog highlighted last week, a collective group of people were successful in getting it removed within one day. Less cause for hope however was a recent YouGov poll  which indicated that people with mental health difficulties are considered to be the group which experiences the most discrimination in our society. All things considered, it seems we have a long way to go. Einstein would appear to be right: it is truly easier to smash an atom than a prejudice. Unfortunately, the only thing that is being smashed at the moment is the dignity of people with mental health difficulties. The fact that our society is contributing to this smashing should be cause for concern to us all.

Dr Simon Clarke
Clinical Psychologist, PhD student and ex-mental health service user
Nottinghamshire Healthcare NHS Trust and University of Nottingham

So far so good for SoFu!

The official launch of the new IMH Centre for Social Futures (SoFu) will take place on Friday 6 December 2013 with opening speeches from Professor Paul Crawford, SoFu Director, and Professor Mike Cooke CBE, Chief Executive of Nottinghamshire Healthcare NHS Trust, as well as other eminent guest speakers. The launch takes place in the Centre of Advanced Studies on the University of Nottingham’s University Park, from 1.30pm to approx. 6pm, with additional presentations, refreshments, and a drinks reception plus networking. For further information or to register your attendance, please email: This email address is being protected from spambots. You need JavaScript enabled to view it.

The Mental Health Research Network is hosting a special event for World Mental Health Day as part of Nottingham Mental Health Awareness Weeks (www.mhaw.org.uk/) to enthuse and inform people with lived experience of mental-health problems, carers and supporters about opportunities for meaningful involvement in mental-health research. The event will include presentations by service-users in research and people championing user/carer collaboration in research. 

Date: 10^th October 2013

Time: 13:30 (refreshments) for 14:00-15:30 (event)

Location: Seminar Room A07, The Institute of Mental Health, University of Nottingham, NG7 2TU.

Spaces are limited, so please book a place via This email address is being protected from spambots. You need JavaScript enabled to view it. / (0115) 82 31302                         .

Programme outline:

13:30                    Doors open (refreshments/displays)

14:00                    Involvement… making a difference!

Karen Medd (Event Chair; service-user research champion)

Celebrating some of the achievements of Patient & Public Involvement

14:10                     "Nothing about me, without me!"

 Using lived experience at any level, or any stage of mental-health research

Andrew Grundy (EQUIP Researcher/Research Associate/service-user)

An interactive workshop exploring different involvement opportunities at various stages of the research process.

14:50                     Training for Involvement (Video presentation)

                                EQUIP Service-User & Carer Advisory Group members

15:00                     PPI Forum: supporting members, supporting research

Andrea Duncan (MHRN PPI Co-ordinator); Craig Beecroft (MHRN Clinical Studies Officer); Jonathan (MHRN PPI Forum member)

Information about the work of the MHRN PPI Forum and how to get involved

15:20                     Just ask 3 Questions to your Doctor to get you involved

                                Prof. Patrick Callaghan (Head of School of Health Sciences; EQUIP Lead, Nottingham)

                                Presenting a new resource to encourage greater involvement in research

15:30                     Close

The event 'Technological Innovations in Mental Healthcare: apps, digital technologies & e-mental health’ is being held on Monday 11^th November 2013 at the Royal College of Physicians, London. It has attracted a wide range of speakers including: 

• Dr Geraldine Strathdee - National Clinical Director of Mental Health, NHS England
• Dr Louise Wood - Deputy Director/Head of NHS Research Infrastructure and Growth, Department of Health
• Professor Chris Hollis - Clinical Director, NIHR MindTech Healthcare Technology Co-Operative
• Rebecca Cotton - Deputy Director, NHS Confederation Mental Health Network
• Professor Simon Lovestone - Director of Research, NIHR Biomedical Research Centre for Mental Health, SLAM & Institute of Psychiatry, Kings College London
• Professor Shôn Lewis – Director, Institute of Brain, Behaviour and Mental Health, University of Manchester
• Sue Dunkerton - Co-Director, HealthTech and Medicines Knowledge Transfer Network (KTN)

There will be demonstrations of apps to support Mental Healthcare, plus a great opportunity to network over lunch and breaks.

Our “early bird” booking offer is open until 30^th September 2013.

Further information on MindTech and the conference can be found via the website: http://www.mindtech.org.uk/