Experiences of living with mental health problems during the COVID-19 pandemic in the UK: a coproduced,participatory qualitative interview study

Purpose

Research is beginning to quantify the impact of COVID-19 on people with pre-existing mental health conditions. Our paper addresses a lack of in-depth qualitative research exploring their experiences and perceptions of how life has changed at this time.

Methods

We used qualitative interviews (N = 49) to explore experiences of the pandemic for people with pre-existing mental health conditions. In a participatory, coproduced approach, researchers with lived experiences of mental health conditions conducted interviews and analysed data as part of a multi-disciplinary research team.

Results

Existing mental health difficulties were exacerbated for many people. People experienced specific psychological impacts of the pandemic, struggles with social connectedness, and inadequate access to mental health services, while some found new ways to cope and connect to the community. New remote ways to access mental health care, including digital solutions, provided continuity of care for some but presented substantial barriers for others. People from black and ethnic minority (BAME) communities experienced heightened anxiety, stigma and racism associated with the pandemic, further impacting their mental health.

Conclusion

There is a need for evidence-based solutions to achieve accessible and effective mental health care in response to the pandemic, especially remote approaches to care. Further research should explore the long-term impacts of COVID-19 on people with pre-existing mental health conditions. Particular attention should be paid to understanding inequalities of impact on mental health, especially for people from BAME communities.

     

Caregiver experiences of social support following stroke

ObjectivesInformal caregivers need to support their loved ones while performing caregiving responsibilities. A phenomenological qualitative study was done to understand the role of social support accessible for stroke caregivers.Materials and methodsThe respondents were enrolled from different organizations or support groups who were conducting activities specifically for stroke victims and/or their caregivers. Data collection was concluded after 10 participants were interviewed as no new major themes were discovered. Hence, saturation of data was obtained with a sample of 10 respondents.ResultsTwo themes were identified from the interviews: “Response to Stroke” and “Stress and Coping”. Categories in theme one “Response to Stroke” were “Work Life Balance”, “Reaction of Other People or Family to Stroke”, and “Expectations and Responsibility from Caregivers”. Categories in theme two “Stress and Coping” were “Impact of Stroke on Abilities of Victim”, “Stressors and Concerns for the Caregivers”, “Strategies used by Caregivers to Cope with Stress”, and “Role of Support Group and Social Support to Stroke Caregiver and Care Recipient”.ConclusionsStroke can lead to stress that can alter the responsibilities of caregivers of stroke victims. The role of social support and support groups was found to be critical for family caregivers to cope with caregiving issues.     

Subjective poverty,mental health,and mortality among Chinese older people: a prospective cohort study from 2008 to 2018

Purpose

The associations of duration of subjective poverty and poverty status with mortality among older people remains inconclusive, and the underlying mechanisms of mental health on them are rarely discussed in population-based epidemiological studies.

Methods

We used the data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) (2008–2018). The Cox regression model was used to estimate hazard ratio (HR) and 95% confidence intervals (CIs) for mortality. Mediation analysis was applied to assess the effect of mental health.

Results

When compared with participants without subjective poverty, those who reported subjective poverty at one time point (2008 or 2011) or two time points (2008 and 2011) had a higher risk of death, with multivariable-adjusted HR (95% CIs) of 1.08 (1.00–1.16) and 1.22 (1.06–1.39), respectively. For poverty status, the multivariable-adjusted HR (95% CIs) of mortality were 0.81 (0.66–0.98) for “just objective poverty” and 0.78 (0.62–0.98) for “neither subjective nor objective poverty” compared with participants who reported “just subjective poverty”, while there was no statistically significant association between “poverty subjectively and objectively” and mortality (HR = 0.88, 95% CI 0.72–1.07). Besides, we found that the proportion mediated by mental health was 26.6%, and age was a significant effect modifier.

Conclusions

Subjective poverty may be associated with a higher risk of death among Chinese older people. This study showed that promoting mental health alone may not substantially reduce socioeconomic inequality in health. Further explorations of measures to tackle the social determinants of health are still needed.

     

Mental Health Hospital Admissions: a Teachable Moment and Window of Opportunity To Promote Change in Drug and Alcohol Misuse

Hospital admissions provide a “teachable moment”. Many patients admitted to mental health hospitals have co-existing substance misuse. As acute symptoms decline, a window of increased insight into factors that contributed to becoming unwell and admission may present. This study used this “teachable” opportunity to assess the acceptability of delivering a brief integrated motivational intervention (BIMI) to inpatients and the feasibility of delivery by inpatient staff. Qualitative interviews were completed  with 21 inpatients experiencing co-occurring schizophrenia-related or bipolar disorder diagnoses and substance misuse who received the BIMI. Twelve staff members completed either individual interviews or a focus group. Four themes were identified from the qualitative interviews with participants; these were openness/readiness to talk about substance use, feeling valued, understanding substance use and helpful skills and processes; each with a number of subthemes. Participants appeared to find the intervention useful; although, felt they did not always have the “headspace”. One theme emerged from the staff data, the acceptability of the approach for inpatient ward staff, which had four subthemes; training in the intervention; delivering the intervention; joint working; and feasibility. Staff considered the targeted style of the BIMI useful. Delivery considerations included “timing” and competing ward duties. Hospital admission presents a natural window of opportunity for staff to start conversations with inpatients about substance misuse.

     

Culture and the therapeutic relationship: Perspectives from Chinese clients

Abstract

Chinese people in the United Kingdom and United States underuse mental health services and, when they do seek help, may find that therapy does not meet their needs. In response to calls in the literature for naturalistic studies of therapy with people of Chinese background, this study used a qualitative, multiple-case approach to examine clients’ individual experiences in depth and detail. Semistructured interviews were conducted with eight Chinese clients. The aim was to investigate how culture might play a role in the therapeutic relationship. Qualitative analysis yielded four key themes concerning clients’ and therapists’ awareness of culture and how this impacted their working relationship: “cultural encapsulation”, “cultural formulation”, “cultural liberation”, and “culture is not important.” Although participants’ perceptions of therapy showed similarities to those reported by clients of European American descent, culture entered into the therapeutic relationship in complex and diverse ways. The findings have implications for delivering culturally sensitive therapies.     

Exploring depressive symptoms and its associates among Bangladeshi older adults amid COVID-19 pandemic: findings from a cross-sectional study

Purpose

Depression, one of the most common mental disorders, is up-surging worldwide amid the ongoing coronavirus disease 2019 (COVID-19) pandemic, especially among the older population. This study aims to measure prevalent depressive symptoms and its associates among older adults amid the COVID-19 pandemic in Bangladesh.

Methods

This cross-sectional study was carried out among 1032 older Bangladeshi adults, aged 60 years and above, through telephone interviews in October 2020. We used a semi-structured questionnaire to collect data on participants’ socio-demographic and lifestyle characteristics, pre-existing medical conditions, and COVID-19-related information. Meanwhile, depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS-15). The binary logistic regression model was used to identify the factors associated with depressive symptoms.

Results

Two-in-five participants showed depressive symptoms on the GDS-15 scale. Poor socioeconomic characteristic such as low family income, dependency on the family for living, recipient of financial support during the pandemic was associated with higher odds of depressive symptoms. Participants with pre-existing medical conditions had 91% higher odds of depressive symptoms. Social isolation, captured in terms of living alone (aOR = 2.11, 95% CI 1.11–4.01), less frequent communication during pandemic (aOR = 1.55, 95% CI 1.07–2.26), perceived loneliness (aOR = 2.25, 95% CI 1.47–3.45), and isolation from others (aOR = 2.45, 95% CI 1.62–3.70) were associated with higher odds of depressive symptoms.

Conclusions

Our study found a sizeable proportion of study participants with depressive symptoms amidst the ongoing pandemic. The findings of the present study call for the urgent need for mental health support package targeting this vulnerable group of population.

     

The Validity of the Psychoanalytic Theory of Paranoid Dynamics

Abstract

Open-ended interviews were conducted with members of the “Execution Team” in Louisiana in order to understand the roles, experiences, and effects of carrying out the death penalty. Fifty of a potential 52 correctional officers who work with executions were interviewed and asked to complete mental health inventories. While emphasizing the importance of security and their professional responsibilities in carrying out the death penalty, the officers stress their respect and decency toward the inmates and all others involved with the process. Although expectably reporting high incidences of exposure to trauma and death, they generally are not clinically depressed. They rely upon religious beliefs, group identity, administrative support, and their capacity to dissociate and rely on diffusion of responsibility to suppress painful emotions. Nevertheless, the officers experience conflicted feelings and frequently report having a hard time carrying out society's “ultimate punishment.”     

Experiences of American Older Adults with Pre-existing Depression During the Beginnings of the COVID-19 Pandemic: A Multicity,Mixed-Methods Study

ObjectiveTo determine the effect of the COVID-19 pandemic on the mental health of older adults with pre-existing major depressive disorder (MDD).ParticipantsParticipants were 73 community-living older adults with pre-existing MDD (mean age 69 [SD 6]) in Los Angeles, New York, Pittsburgh, and St Louis.Design and MeasurementsDuring the first 2 months of the pandemic, the authors interviewed participants with a semistructured qualitative interview evaluating access to care, mental health, quality of life, and coping. The authors also assessed depression, anxiety, and suicidality with validated scales and compared scores before and during the pandemic.ResultsFive themes from the interviews highlight the experience of older adults with MDD: 1) They are more concerned about the risk of contracting the virus than the risks of isolation. 2) They exhibit resilience to the stress and isolation of physical distancing. 3) Most are not isolated socially, with virtual contact with friends and family. 4) Their quality of life is lower, and they worry their mental health will suffer with continued physical distancing. 5) They are outraged by an inadequate governmental response to the pandemic. Depression, anxiety, and suicidal ideation symptom scores did not differ from scores before the pandemic.ConclusionMost older adults with pre-existing MDD show resilience in the first 2 months of the COVID-19 pandemic but have concerns about the future. Policies and interventions to provide access to medical services and opportunities for social interaction are needed to help to maintain mental health and quality of life as the pandemic continues.     

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses

Purpose

The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these.

Methods

We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach.

Results

We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future.

Conclusion

Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

     

“I want to fit in… but I don’t want to change myself fundamentally”: A qualitative exploration of the relationship between masking and mental health for autistic teenagers

BackgroundPrevious research has identified an association between masking and mental health for autistic people. However, the direction of causality and mechanisms involved in this relationship are not well understood. This qualitative study aimed to investigate autistic teenagers’ experiences of masking, mental health and how the two develop and interact.MethodsTwenty autistic teenagers took part in a semi-structured interview. The interviews were analysed using Reflexive Thematic Analysis.ResultsFrom the analysis, one theme was identified to conceptualise masking as described by participants. Five more inter-related themes were identified, each involved both in the relationship between masking and mental health and conversely in the relationship between authenticity and mental health. Participants described how masking and mental health both influence each other, and both are influenced by social and environmental factors.ConclusionsThe findings are consistent with previous research indicating that masking is associated with mental health difficulties. Our analysis presents a broader conceptualisation of masking than previously defined in the literature, placing social oppression of autistic people at the heart of the relationship between masking and mental health. The findings have implications for diagnostic services, post-diagnostic support and therapeutic interventions, highlighting the need to challenge deficit-based narratives of autism.     

An online intervention for vulnerable young adults: identifying mechanisms of change using a grounded theory approach

Purpose

The purpose of this study is to qualitatively identify the mechanisms of change as young adults, whose parents have a mental illness and/or substance use issue, navigate their way through a 6-week, moderated online intervention.

Methods

Using a qualitative, grounded theory approach, data were collected and triangulated for analysis from participants before, during, and after engaging in the intervention. First, 31 young people’s motivations for enrolling in the intervention were identified from one open ended question on an online survey. Second, online chat sessions were analysed to identify those topics the 31 participants engaged in throughout the intervention. Finally, 19 interviews were conducted 2 weeks post-intervention, to ascertain participants’ perceptions of the impacts of the intervention and how the intervention promoted changes.

Results

The main storyline was that of participants “making sense” of their parents, themselves and other relationships, in collaboration with peers, in a safe online space. This storyline of “making sense” drove their motivation to join the intervention and was the focus of the online chats. After the intervention, some were closer to having “made sense” of their families while others struggled differentiating themselves away from their families. An anonymous, professionally moderated online site afforded participants opportunities to think about who they were and for some, who they wanted to be.

Conclusion

Generating an explanatory theory of how vulnerable young people navigate their way through an online intervention provides important information that can be used to inform future services, interventions, and research.

     

A longitudinal study on the COVID-19 pandemic and its divergent effects on social participation and mental health across different study groups with and without mental disorders

Purpose

With the rapid spread of COVID-19 and the restrictions imposed in many parts of the world, there is growing concern about its impact on mental health. This longitudinal study investigated the social participation, social inclusion and psychological well-being in adults with and without mental disorders before the beginning of the pandemic, as well as during and after strict lockdown restrictions in Germany.

Methods

The sample (n = 106) consisted of three groups: participants with a chronic mental disorder, with an acute mental disorder, and without a mental disorder at the time of the initial survey. Parameters of interest were assessed using the Measure of Participation and Social Inclusion for Use in People with a Chronic Mental Disorder (F-INK), the Index for the Assessment of Health Impairments (IMET) and the Brief Symptom Inventory (BSI-18).

Results

The perceived impairments in social participation and the associated changes in behaviour varied depending on the presence of a mental disorder at the time of the initial survey and were largely temporary, i.e. limited to the period of strict lockdown restrictions. We found no further detrimental effects on mental health 4 weeks after lockdown or later, when a policy of physical distancing was in place.

Conclusion

Overall, our findings suggest a general resilience to the official restrictions and measures as well as the pandemic itself. However, further efforts are needed to improve the situation of people with chronic mental disorders and their limited opportunities for social participation.

     

“Lives of despair” at risk for “deaths of despair”: tracking an under-recognized,vulnerable population

Purpose

The substantial and unexpected increase in “deaths of despair” in the US (e.g., deaths from drug overdose, suicide, and alcohol-related liver diseases) reported by economists Case and Deaton in 2015 raises questions about the number and characteristics of US adults potentially living “lives of despair” with these problems.

Methods

We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) to examine population estimates and characteristics of adults with lifetime history of substance use disorder (SUD) and suicide attempt, or either condition alone, as compared to those with neither.

Results

An estimated 7.2 million adults had both lifetime SUD and suicide attempt and 78.8 million had either. Those with both faced far more psychosocial adversities, familial adverse experiences and psychiatric disorders compared to those with the other two groups, and reported greater mental health service utilization. Multivariable analysis showed that psychiatric multimorbidity and violence were the strongest correlates of having both conditions as compared to neither while those with either condition fell in between.

Conclusion

A substantial number of US adults live with a lifetime SUD and suicide attempt with a multiplicity of additional socioeconomic, psychiatric and familial problems. While their utilization of mental health care service exceeds those with either or neither conditions, quality of life remained much poorer, suggesting that mental health treatment alone may not be enough to mitigate their sufferings, and a combination of both social policy support and quality mental health care may be needed.

     

Developing and testing a principle-based fidelity index for peer support in mental health services

Purpose

Evidence suggests that the distinctive relational qualities of peer support—compared to clinical-patient relationships—can be eroded in regulated healthcare environments. Measurement of fidelity in trials of peer support is lacking. This paper reports the development and testing of a fidelity index for one-to-one peer support in mental health services, designed to assess fidelity to principles that characterise the distinctiveness of peer support.

Methods

A draft index was developed using expert panels of service user researchers and people doing peer support, informed by an evidence-based, peer support principles framework. Two rounds of testing took place in 24 mental health services providing peer support in a range of settings. Fidelity was assessed through interviews with peer workers, their supervisors and people receiving peer support. Responses were tested for spread and internal consistency, independently double rated for inter-rater reliability, with feedback from interviewees and service user researchers used to refine the index.

Results

A fidelity index for one-to-one peer support in mental health services was produced with good psychometric properties. Fidelity is assessed in four principle-based domains; building trusting relationships based on shared lived experience; reciprocity and mutuality; leadership, choice and control; building strengths and making connections to community.

Conclusions

The index offers potential to improve the evidence base for peer support in mental health services, enabling future trials to assess fidelity of interventions to peer support principles, and service providers a means of ensuring that peer support retains its distinctive qualities as it is introduced into mental health services.

     

Commitment under pressure: Experienced therapists' inner work during difficult therapeutic impasses

Abstract

Interviews were conducted to explore the recall of impasse experiences of 12 highly skilled and experienced therapists. Participants were interviewed in depth individually about a specific impasse from their experience that resolved successfully. The transcribed interviews were analysed using qualitative methodology. The authors found that participants understood their reported impasse experiences as important for their professional development. The category of “helpful subjective presence” describes the mode of being with patients that the participants found therapeutic. The categories of “losing hope” and “difficult feelings in the therapist in the here and now” are processes that threaten the helpful presence. The participants' inner work on the two latter categories is identified as a key to the successful resolution of impasses.     

How service users and carers understand,perceive, rephrase,and communicate about “depressive episode” and “schizophrenia” diagnoses: an international participatory research

Background

For ICD-11, the WHO emphasized the clinical utility of communication and the need to involve service users and carers in the revision process.

Aims

The objective was to assess whether medical vocabulary was accessible, which kinds of feelings it activated, whether and how users and carers would like to rephrase terms, and whether they used diagnosis to talk about mental health experiences.

Method

An innovative protocol focused on two diagnoses (depressive episode and schizophrenia) was implemented in 15 different countries. The same issues were discussed with users and carers: understanding, feelings, rephrasing, and communication.

Results

Most participants reported understanding the diagnoses, but associated them with negative feelings. While the negativity of “depressive episode” mostly came from the concept itself, that of “schizophrenia” was largely based on its social impact and stigmatization associated with “mental illness”.

When rephrasing “depressive episode”, a majority kept the root “depress*”, and suppressed the temporal dimension or renamed it. Almost no one suggested a reformulation based on “schizophrenia”. Finally, when communicating, no one used the phrase “depressive episode”. Some participants used words based on “depress”, but no one mentioned “episode”. Very few used “schizophrenia”.

Conclusion

Data revealed a gap between concepts and emotional and cognitive experiences. Both professional and experiential language and knowledge have to be considered as complementary. Consequently, the ICD should be co-constructed by professionals, service users, and carers. It should take the emotional component of language, and the diversity of linguistic and cultural contexts, into account.

     

Seeking safety and empathy: Adolescent health seeking behavior during pregnancy and early motherhood in central Uganda

PurposeTo explore adolescent health seeking behavior during pregnancy and early motherhood in order to contribute to health policy formulation and improved access to health care. This will in long-term have an impact on the reduction of morbidity and mortality among adolescent mothers and their newborns.MethodsThis was a qualitative study that employed focus group discussions (FGDs) among adolescent girls (10–19 years) and key informant (KI) interviews with health workers. Age for FGD participants ranged from 16 to 19 years. The FGD participants were recruited while seeking antenatal care for their first pregnancy or immunization service for their first child, not being older than 6 months. Six health facilities were selected. Key informants were purposefully selected on the basis of being in-charge of maternity units. Thirteen FGDs comprising of a total of 92 adolescent girls were conducted. The FGDs were held with homogeneously constituted categories; married pregnant adolescents (5), unmarried pregnant adolescents (3) and married or not married adolescents with children (5). Semi structured interviews were held with six KIs who were in-charge of maternity units of health facilities. Latent content analysis technique was used for data analysis.ResultsTwo main themes emerged; ‘feeling exposed and powerless’, and ‘seeking safety and empathy’. The categories identified in the first theme were “the dilemma of becoming an adolescent mother” and “lack of decision power”. In the second theme the following categories were identified: “cultural practices and beliefs about birth”, “expectations and experiences”, “transport, a key determinant to health seeking”, and “dealing with constraints”. Adolescents felt exposed and powerless due to the dilemma of early motherhood and lack of decision making power. The adolescent mothers seemed to be in continuous quest for safety and empathy. In so doing they are part of cultural practices and beliefs about birth. They had expectations about the health care services but their experiences of the services were rather negative. Transport was a key determinant for health seeking and adolescents to some extent had learnt how to cope with constraints they face.Conclusion and implicationsPregnant adolescents seek health care in both modern and traditional health sectors in order to get safety and empathy. However, our findings indicate that they mostly utilize the traditional sector because it is most accessible in terms of distance, cost and cultural context. Adolescent mothers are disempowered in decision making because of their pregnancy state which often puts them in dilemma. We therefore suggest that policy makers need to improve health systems (including the traditional sector) especially maternal health services for adolescent girls. Improved infrastructure and attitudes of health worker as well as training in delivery of adolescent health services is critical.     

A house is not a home: a network model perspective on the dynamics between subjective quality of living conditions,social support,and mental health of refugees and asylum seekers

Background:

Providing adequate living conditions for forcibly displaced people represents a significant challenge for host countries such as Germany. This study explores refugee mental health’s reciprocal, dynamic relationship with post-migration living conditions and social support.

Methods:

The study sample included 325 Arabic- or Farsi-speaking asylum seekers and refugees residing in Germany since 2014 and seeking mental health treatment. Associations between reported symptoms of post-traumatic stress and depression and the subjective quality of living conditions and perceived social support were analyzed using a two-level approach including multiple linear regression and network analyses.

Results:

Post-migration quality of living conditions and perceived social support were significantly associated with negative mental health outcomes on both levels. In the network, both post-migration factors were negatively connected with overlapping symptoms of psychiatric disorders, representing potential target symptoms for psychological treatment.

Conclusion:

Post-migration quality of living conditions and social support are important factors for refugee mental health and should be targeted by various actors fostering mental well-being and integration.

     

Risk and protective factors for mental health at a youth mass gathering

Background

Mass gatherings are well-documented for their public health risks; however, little research has examined their impact on mental health or focused on young people specifically. This study explores risk and protective factors for mental health at mass gatherings, with a particular focus on characterising attendees with high levels of psychological distress and risk taking.

Method

Data collection was conducted in situ at “Schoolies”, an annual informal week-long mass gathering of approximately 30,000 Australian school leavers. Participants were 812 attendees of Schoolies on the Gold Coast in 2015 or 2016 (74% aged 17 years old).

Results

In both years, attendee mental health was found to be significantly better than population norms for their age peers. Identification with the mass gathering predicted better mental health, and this relationship became stronger across the course of the mass gathering. Attendees with high levels of psychological distress were more likely to be male, socially isolated, impulsive, and in a friendship group where risk taking was normative.

Conclusions

Mass gatherings may have a net benefit for attendee mental health, especially for those attendees who are subjectively committed to the event. However, a vulnerable subgroup of attendees requires targeted mental health support.