Tuesday, May 12, 2015

Teen responses when a younger school-age sibling has been bullied

 2015 Apr 3;20(2):131-147. Epub 2014 Dec 10.

Teen responses when a younger school-age sibling has been bullied.

Author information

  • 1Department of Child and family Studies, Syracuse University , Syracuse , NY , USA.
  • 2Horsham Clinic , Philadelphia , PA , USA.

Abstract

The prevalence of bullying among children, and the sometimes tragic consequences as a result, has become a major concern in schools. The larger research for this study reported on in-depth interviews with 28 elementary and middle school-age boys and girls (7-12 years) who had experienced various forms of bullying and relational aggression by their peers, mostly on school grounds, and the responses of their parents and teachers. Responses of the children's teen siblings to the younger child's revelations of being bullied are the focus of this report. In-depth interviews with each teen sibling (n = 28) and with each bullied child revealed how the children viewed the teen siblings' supportive strategies. Almost all the children (89%) reported that their older siblings talked with them and offered advice. The teen siblings shared with the younger ones that they too (71%) had been bullied, or they knew someone who had been bullied (18%). Teens gave the advice to 'bully back' to 11% and advice to 'tell someone' to 32% of the younger children. The children felt quite positive about their older siblings' advice (89%), which did differ depending on the bullied child's gender. Teen siblings gave advice to 'avoid bullies' to 77% of female and to 27% of male younger children.

Classroom Norms of Bullying Alter the Degree to Which Children Defend in Response to Their Affective Empathy and Power

 2015 May 11. [Epub ahead of print]

Classroom Norms of Bullying Alter the Degree to Which Children Defend in Response to Their Affective Empathy and Power.

Abstract

This study examined whether the degree to which bullying is normative in the classroom would moderate associations between intra- (cognitive and affective empathy, self-efficacy beliefs) and interpersonal (popularity) factors and defending behavior. Participants were 6,708 third- to fifth-grade children (49% boys; Mage = 11 years) from 383 classrooms. Multilevel modeling analyses revealed that children were more likely to defend in response to their affective empathy in classrooms with high levels of bullying. In addition, popular students were more likely to support victims in classrooms where bullying was associated with social costs. These findings highlight the importance of considering interactions among individual and contextual influences when trying to understand which factors facilitate versus inhibit children's inclinations to defend others.

A relational framework for understanding bullying: Developmental antecedents and outcomes

 2015 May-Jun;70(4):311-321.

A relational framework for understanding bullying: Developmental antecedents and outcomes.

Author information

  • 1Department of Educational Psychology.
  • 2T. Denny Sanford School of Social and Family Dynamics, Arizona State University.

Abstract

This article reviews current research on the relational processes involved in peer bullying, considering developmental antecedents and long-term consequences. The following themes are highlighted: (a) aggression can be both adaptive and maladaptive, and this distinction has implications for bullies' functioning within peer social ecologies; (b) developmental antecedents and long-term consequences of bullying have not been well-distinguished from the extant research on aggressive behavior; (c) bullying is aggression that operates within relationships of power and abuse. Power asymmetry and repetition elements of traditional bullying definitions have been hard to operationalize, but without these specifications and more dyadic measurement approaches there may be little rationale for a distinct literature on bullying-separate from aggression. Applications of a relational approach to bullying are provided using gender as an example. Implications for future research are drawn from the study of relationships and interpersonal theories of developmental psychopathology. 

Translating research to practice in bullying prevention

 2015 May-Jun;70(4):322-332.

Translating research to practice in bullying prevention.

Author information

  • 1University of Virginia.

Abstract

Bullying continues to be a concern in schools and communities across the United States and worldwide, yet there is uncertainty regarding the most effective approaches for preventing it and addressing its impacts on children and youth. This paper synthesizes findings from a series of studies and meta-analyses examining the efficacy of bullying prevention programs. This paper considers some methodological issues encountered when testing the efficacy and effectiveness of bullying prevention and intervention approaches. It also identifies several areas requiring additional research in order to increase the effectiveness of bullying prevention efforts in real-world settings. Drawing upon a public health perspective and findings from the field of prevention science, this paper aims to inform potential future directions for enhancing the adoption, high quality implementation, and dissemination of evidence-based bullying prevention programs. It is concluded that althoughbullying prevention programs can be effective in reducing bullying and victimization among school-aged youth, there is a great need for more work to increase the acceptability, fidelity, and sustainability of the existing programs in order to improve bullying-related outcomes for youth. The findings from this review are intended to inform both policy and public health practice related to bullying prevention. 

Law and policy on the concept of bullying at school

 2015 May-Jun;70(4):333-343.

Law and policy on the concept of bullying at school.

Author information

  • 1Curry School of Education.
  • 2Institute on Family & Neighborhood Life, Clemson University.

Abstract

The nationwide effort to reduce bullying in U.S. schools can be regarded as part of larger civil and human rights movements that have provided children with many of the rights afforded to adult citizens, including protection from harm in the workplace. Many bullied children find that their schools are hostile environments, but civil rights protections against harassment apply only to children who fall into protected classes, such as racial and ethnic minorities, students with disabilities, and victims of gender harassment or religious discrimination. This article identifies the conceptual challenges that bullying poses for legal and policy efforts, reviews judicial and legislative efforts to reduce bullying, and makes some recommendations for school policy. Recognition that all children have a right to public education would be one avenue for broadening protection against bullying to all children. 

Understanding the psychology of bullying: Moving toward a social-ecological diathesis-stress model

 2015 May-Jun;70(4):344-353.

Understanding the psychology of bullying: Moving toward a social-ecological diathesis-stress model.

Author information

  • 1Department of Educational Psychology.
  • 2Faculty of Education, Department of Educational and Counselling Psychology and Special Education, University of British Columbia.

Abstract

With growing recognition that bullying is a complex phenomenon, influenced by multiple factors, research findings to date have been understood within a social-ecological framework. Consistent with this model, we review research on the known correlates and contributing factors in bullying/victimization within the individual, family, peer group, school and community. Recognizing the fluid and dynamic nature of involvement in bullying, we then expand on this model and consider research on the consequences of bullying involvement, as either victim or bully or both, and propose a social-ecological, diathesis-stress model for understanding the bullying dynamic and its impact. Specifically, we frame involvement in bullying as a stressful life event for both children who bully and those who are victimized, serving as a catalyst for a diathesis-stress connection between bullying, victimization, and psychosocial difficulties. Against this backdrop, we suggest that effectivebullying prevention and intervention efforts must take into account the complexities of the human experience, addressing both individual characteristics and history of involvement in bullying, risk and protective factors, and the contexts in which bullying occurs, in order to promote healthier social relationships. 

Four decades of research on school bullying: An introduction

Am Psychol. 2015 May-Jun;70(4):293-299.

Four decades of research on school bullying: An introduction.

Author information

  • 1Faculty of Education, Department of Educational and Counselling Psychology and Special Education.
  • 2Faculty of Education, Department of Educational Psychology, University of Nebraska-Lincoln.

Abstract

This article provides an introductory overview of findings from the past 40 years of research on bullying among school-aged children and youth. Research on definitional and assessment issues in studying bullying and victimization is reviewed, and data on prevalence rates, stability, and forms of bullying behavior are summarized, setting the stage for the 5 articles that comprise this American Psychologist special issue on bullying and victimization. These articles address bullying, victimization, psychological sequela and consequences, ethical, legal, and theoretical issues facing educators, researchers, and practitioners, and effective prevention and intervention efforts. The goal of this special issue is to provide psychologists with a comprehensive review that documents our current understanding of the complexity of bullying among school-aged youth and directions for future research and intervention efforts. 

Friday, May 1, 2015

The federal medical loss ratio rule: implications for consumers in year 3

 2015 Mar;6:1-11.

The federal medical loss ratio rule: implications for consumers in year 3.

Author information

  • 1Department of Health Administration, School of Allied Health Professions, Virginia Commonwealth University. mccue@vcu.edu

Abstract

For the past three years, the Affordable Care Act has required health insurers to pay out a minimum percentage of premiums in medical claims or quality improvement expenses--known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2013 were $325 million, less than one-third the amount paid out in 2011, indicating much greater compliance with the MLR rule. Insurers' spending on quality improvement remained low, at less than 1 percent of premiums. Insurers' administrative and sales costs, such as brokers' fees, and profit margins have reduced slightly but remain fairly steady. In the first three years under this regulation, total consumer benefits related to the medical loss ratio--both rebates and reduced overhead--amounted to over $5 billion. This was achieved without a great exodus of insurers from the market.

Should people considered obese be protected by human rights laws?

Should people considered obese be protected by human rights laws?



"He says the other way of protecting people could be banning “appearance bias” — discrimination based on how someone looks.
The number of severely obese Canadians has skyrocketed over the last few decades, and Bogart argues the law needs to keep up with changes in society. He uses changing attitudes toward same-sex marriage and smoking as examples."

"Stepping aside from its awkward and embarrassing rollout and its politically biased claims and counterclaims, the ACA appears to be achieving many of its goals."

 2015 Apr 7. pii: S0149-2918(15)00144-7. doi: 10.1016/j.clinthera.2015.03.007. [Epub ahead of print]

The Patient Protection and Affordable Care Act: Politics and Pills.



"Stepping aside from its awkward and embarrassing rollout and its politically biased claims and counterclaims, the ACA appears to be achieving many of its goals. More people are now covered than in the past, and costs are either coming down or are increasing by smaller increments; the Congressional Budget Office indicates both lower premiums and a meaningful contribution to deficit reduction; and there is evidence of innovation, through the creation of 4350 accountable care organizations nationwide.4,5 Contrary to the Republicans’ warning about lengthy waiting periods, a recent article in the New England Journal of Medicine showed that as a consequence of the ACA there has been “…improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times.”6"

From NYU: How will the Affordable Care Act affect the use of health care services?

 2015 Feb;4:1-15.

How will the Affordable Care Act affect the use of health care services?

Author information

  • 1Robert F. Wagner Graduate School of Public Service, New York University.

Abstract

In January 2014, the Affordable Care Act extended access to health insurance coverage to an estimated 30 million previously uninsured people. This issue brief provides state-level estimates of the increased demand for physician and hospital services that is expected to result from expanded access and assesses the sufficiency of the existing supply of providers to accommodate the anticipated increase in demand. We project that primary care providers will see, on average, 1.34 additional office visits per week, accounting for a 3.8 percent increase in visits nationally. Hospital outpatient departments will see, on average, 1.2 to 11.0 additional visits per week, or an average increase of about 2.6 percent nationally. Increases of the magnitude likely to be generated by the Affordable Care Act will have modest effects on the demand for health services, and the existing supply of providers should be sufficient to accommodate this increased demand.

Perceptions of risk from nanotechnologies and trust in stakeholders: a cross sectional study of public, academic, government and business attitudes

 2015 Apr 26;15(1):424. [Epub ahead of print]

Perceptions of risk from nanotechnologies and trust in stakeholders: a cross sectional study of public, academic, government and business attitudes.

Author information

  • 1Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia. acap1921@uni.sydney.edu.au.
  • 2Environmental Health Branch, Health Protection NSW, 73 Miller St, North Sydney, Sydney, Australia. acap1921@uni.sydney.edu.au.
  • 3Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia. james.gillespie@sydney.edu.au.
  • 4University Centre for Rural Health, School of Public Health, University of Sydney, Sydney, Australia. margaret.rolfe@sydney.edu.au.
  • 5Environmental Health Branch, Health Protection NSW, 73 Miller St, North Sydney, Sydney, Australia. wayne.smith@doh.health.nsw.gov.au.

Abstract

BACKGROUND:

Policy makers and regulators are constantly required to make decisions despite the existence of substantial uncertainty regarding the outcomes of their proposed decisions. Understanding stakeholder views is an essential part of addressing this uncertainty, which provides insight into the possible social reactions and tolerance of unpredictable risks. In the field of nanotechnology, large uncertainties exist regarding the real and perceived risks this technology may have on society. Better evidence is needed to confront this issue.

METHODS:

We undertook a computer assisted telephone interviewing (CATI) survey of the Australian public and a parallel survey of those involved in nanotechnology from the academic, business and government sectors. Analysis included comparisons of proportions and logistic regression techniques. We explored perceptions of nanotechnology risks both to health and in a range of products. We examined views on four trust actors.

RESULTS:

The general public's perception of risk was significantly higher than that expressed by other stakeholders. The public bestows less trust in certain trust actors than do academics or government officers, giving its greatest trust to scientists. Higher levels of public trust were generally associated with lower perceptions of risk. Nanotechnology in food and cosmetics/sunscreens were considered riskier applications irrespective of stakeholder, while familiarity with nanotechnology was associated with a reduced risk perception.

CONCLUSIONS:

Policy makers should consider the disparities in risk and trust perceptions between the public and influential stakeholders, placing greater emphasis on risk communication and the uncertainties of risk assessment in these areas of higher concern. Scientists being the highest trusted group are well placed to communicate the risks of nanotechnologies to the public.

Lung cancer risk by years since quitting in 30+ pack year smokers

 2015 Apr 29. pii: 0969141315579119. [Epub ahead of print]

Lung cancer risk by years since quitting in 30+ pack year smokers.

Author information

  • 1Division of Cancer Prevention, National Cancer Institute pp4f@nih.gov.
  • 2Division of Cancer Prevention, National Cancer Institute.

Abstract

OBJECTIVE:

Current United States recommendations for low-dose computed tomography (LDCT) lung cancer screening limit eligibility to ever-smokers with 30+ pack-years, with former smokers eligible only within 15 years of quitting. The 15 year limit is partly based on perceived decreases in lung cancer risk as years since quitting (YSQ) increase. We examine the relationship between lung cancer risk and YSQ among 30+ pack-year former smokers.

METHODS:

In the Prostate, Lung, Colorectal, and Ovarian trial, participants aged 55-74 were randomized to screening or usual care; screened subjects received annual chest-radiographs for lung cancer screening. Subjects completed a baseline questionnaire; smoking history included average cigarettes per day and age at starting and stopping smoking. Subjects were followed 13 years. Cox proportional hazards models were utilized to estimate hazard ratios (HRs) associated with YSQ, with YSQ treated as a time-varying covariate. The models adjusted for age and sex.

RESULTS:

Of 154899 subjects randomized, 27101 were former smokers with 30+ pack-years, and 69182 were never smokers. HRs relative to never smokers ranged from 30.8 (95% CI:23.4-40.5) for YSQ ≤5 to 6.4 (95% CI:5.1-8.0) for YSQ > 30. For YSQ of >10-15, >15-20, and >20-25, HRs were 14.8 (95% CI:11.9-18.2), 13.5 (95% CI:11.3-16.2), and 9.9 (95% CI: 8.1-12.0), respectively.

CONCLUSIONS:

Lung cancer risk decreases gradually with YSQ in 30+ pack year former smokers. A range of upper limits on YSQ may be supportable for LDCT screening.

An International Study of Research Misconduct Policies

 2015;22(5):249-266.

An International Study of Research Misconduct Policies.

Author information

  • 1a National Institute of Environmental Health Sciences, National Institutes of Health , Research Triangle Park , North Carolina , USA.

Abstract

Research misconduct is an international concern. Misconduct policies can play a crucial role in preventing and policing research misconduct, and many institutions have developed their own policies. While institutional policies play a key role in preventing and policing misconduct, national policies are also important to ensure consistent promulgation and enforcement of ethical standards. The purpose of this study was to obtain more information about research misconduct policies across the globe. We found that twenty-two of the top forty research and development funding countries (55%) had a national misconduct policy. Four countries (18.2%) are in the process of developing a policy, and four (18.2%) have a national research ethics code but no misconduct policy. All twenty-two countries (100%) with national policies included fabrication, falsification, and plagiarism in the definition of misconduct, but beyond that there was considerable diversity. Unethical authorship was mentioned in 54.6% of the misconduct definitions, followed by unethical publication practices (36.4%), conflict of interest mismanagement (36.4%), unethical peer review (31.8%), misconduct related to misconduct investigations (27.3%), poor record keeping (27.3%), other deception (27.3%), serious deviations (22.7%), violating confidentiality (22.7%), and human or animal research violations (22.7%). Having a national policy was positively associated with research and development funding ranking and intensiveness. To promote integrity in international research collaborations, countries should seek to harmonize and clarify misconduct definitions and develop procedures for adjudicating conflicts when harmonization does not occur.

In case you forgot, its Friday.

In case you forgot, its Friday.

Thursday, April 30, 2015

Federalism, the Economic-Industrial Health Care Complex and High-Cost Pharmaceutical Assistance in Brazil

 2015 Apr;20(4):1165-1176.

Federalism, the Economic-Industrial Health Care Complex and High-Cost Pharmaceutical Assistance in Brazil.

[Article in English, Portuguese]

Author information

  • 1Escola de Administração de Empresas de São Paulo, Fundação Getúlio Vargas, São Paulo, SP, Brasil, emassard@gmail.com.
  • 2Escola Nacional de Saúde Pública, Fiocruz.

Abstract

Brazil has a relevant, although relatively unknown, special medicines programme that distributes high-cost products, such as drugs needed for cancer treatments. In 2009, the purchase of these medicines became the responsibility of the Brazilian Federal Government. Until then, there were no clear norms regarding the responsibilities, in terms of the management/financing of these medicines, of the Brazilian Federal Government and of the states themselves. This qualitative study analyses the policy process needed to transfer this programme to the central government. The study examines the reports of the Tripartite Commission between 2000 and 2012, and in-depth interviews with eleven key informants were conducted. The study demonstrates that throughout the last decade, institutional changes have been made in regard to the federal management of these programmes (such as recentralisation of the purchasing of medicines). It concludes that these changes can be explained because of the efficiency of the coordinating mechanisms of the Federal Government. These findings reinforce the idea that the Ministry of Health is the main driver of public health policies, and it has opted for the recentralisation of activities as a result of the development project implicit in the agenda of the Industrial and Economic Heal.

The uncomfortable truth behind Chipotle's GMO ban



The uncomfortable truth behind Chipotle's GMO ban



"If its centerpiece can be a foil-wrapped obesity bomb — a barbacoa burrito on a flour tortilla with rice, sour cream and guacamole contains 995 calories and 53 grams of fat, according to the company’s Web site — well, that’s the customer’s choice.
The pork comes from free-range pigs!"


Read more: http://www.washingtonpost.com/opinions/burrito-bunkum/2015/04/29/a4cd8382-ed18-11e4-8666-a1d756d0218e_story.html?wprss=rss_opinions#ixzz3YoILiBOM

Depression Literacy Among American Indian Older Adults

 2015 Apr 29:1-14. [Epub ahead of print]

Depression Literacy Among American Indian Older Adults.

Author information

  • 1a School of Social Work, University of South Dakota , Sioux Falls , South Dakota , USA.

Abstract

Older American Indians experience high rates of depression and other psychological disorders, yet little research exist on the depression literacy of this group. Depression literacy is fundamental for individuals seeking help for depression in a timely and appropriate manner. In the present study the authors examine levels and predictors of knowledge of depression symptoms in a sample of rural older American Indians (N = 227) living in the Midwestern United States. Data from self-administered questionnaires indicate limited knowledge of depression and negative attitudes toward seeking help for mental health problems. Additional findings and implications for social work practice and policy are discussed.

"...apart from ethics, what is the role of philosophy 'at the bedside'?"

 2015 Jun;21(3):357-364. doi: 10.1111/jep.12370.

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care.

Author information

  • 1Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK.

Abstract

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.

Wednesday, April 29, 2015

Concussion under-reporting and pressure from coaches, teammates, fans, and parents

 2015 Apr 20;134:66-75. doi: 10.1016/j.socscimed.2015.04.011. [Epub ahead of print]

Concussion under-reporting and pressure from coaches, teammates, fans, and parents.

Author information

  • 1Harvard School of Public Health, Department of Social and Behavioral Science, USA; National Collegiate Athletic Association, Sport Science Institute, USA; Harvard University, Edmond J. Safra Center for Ethics, USA. Electronic address: emk329@mail.harvard.edu.
  • 2University of Vermont, College of Education and Social Services, Department of Education, USA. Electronic address: bgarnett@uvm.edu.
  • 3Clark University, Department of Clinical Psychology, USA. Electronic address: mhawrilenko@clarku.edu.
  • 4Harvard University, Edmond J. Safra Center for Ethics, USA; Harvard University, Interfaculty Initiative in Health Policy, USA; Boston Children's Hospital, Division of Sports Medicine, USA. Electronic address: cbaugh@g.harvard.edu.
  • 5Boston Children's Hospital, Division of Adolescent & Young Adult Medicine, USA; Harvard Medical School, Department of Pediatrics, USA. Electronic address: jerel.calzo@childrens.harvard.edu.

Abstract

Concussions from sport present a substantial public health burden given the number of youth, adolescent and emerging adult athletes that participate in contact or collision sports. Athletes who fail to report symptoms of a suspected concussion and continue play are at risk of worsened symptomatology and potentially catastrophic neurologic consequences if another impact is sustained during this vulnerable period. Understanding why athletes do or do not report their symptoms is critical for developing efficacious strategies for risk reduction. Psychosocial theories and frameworks that explicitly incorporate context, as a source of expectations about the outcomes of reporting and as a source of behavioral reinforcement, are useful in framing this problem. The present study quantifies the pressure that athletes experience to continue playing after a head impact-from coaches, teammates, parents, and fans-and assesses how this pressure, both independently and as a system, is related to future concussion reporting intention. Participants in the study were 328 male and female athletes from 19 teams competing in one of seven sports (soccer, lacrosse, basketball, softball, baseball, volleyball, field hockey) at four colleges in the northeast region of the United States. Results found that more than one-quarter of the sample had experienced pressure from at least one source to continue playing after a head impact during the previous year. Results of a latent profile mixture model indicated that athletes who experienced pressure from all four of the measured sources were significantly more likely to intend to continue playing in the future than were athletes who had not experienced pressure from all sources, or only pressure from coaches and teammates. These findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting cognitions.

Obesity risk soars after one hour of TV

Obesity risk soars after one hour of TV

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives

Int Clin Psychopharmacol. 2015 Apr 23. [Epub ahead of print]

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives.

Author information

  • 1Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand.

Abstract

Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other's views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.