Inpatient psychiatric rehabilitation services for people with complex psychosis promote independent living and reduce readmissions through multidisciplinary recovery-based practice. Yet, little research has explored how these services are experienced by patients and staff, partly due to the difficulties of conducting qualitative research in such settings using interviews and focus groups. We therefore lack an in-depth understanding of how inpatient rehabilitation operates on the ground, including which aspects are experienced as helpful/unhelpful and which factors determine the feasibility/success of recovery-based practice.

We conducted an ethnographic study of a 16-bed inpatient rehabilitation ward in London comprising six months of participant observation followed by 20 semi-structured interviews with patients (n = 7) and staff (n = 13). For participant observation, over 200 pages of fieldnotes were taken contemporaneously. Semi-structured interviews were audio-recorded and transcribed verbatim. Data were analysed using grounded theory and situational analysis.

Our analysis highlights the fundamental importance of relationality in inpatient rehabilitation. Specifically, complex psychosis is characterised by relational impairments and divergences that lead to significant disability. Working with this complex patient group therefore requires nuanced and specialist relational skills. On the ward, these skills were actively nurtured by staff, especially those at lower pay grades, to provide the essential scaffolding for recovery-based practice. Yet, ward staff were often prevented from prioritising therapeutic relations by prevailing structural and institutional arrangements. For example, greater importance was attached to completing technical and bureaucratic interventions; patient contact was reduced for more experienced staff; and staffing levels and material resources for rehabilitation activities were limited. Already feeling underequipped, staff members described how their motivation to cultivate therapeutic relations was further reduced by experiences of structural inequalities inside and outside the ward and, more proximally, by limited psychological and occupational support structures. The consequent undermining of recovery-based practice led to patients experiencing treatment as more restrictive and less therapeutic than it could have been.

Relationality is a key determinant of the experience of treatment within psychiatric units, and yet the subversion of therapeutic relations identified in this study reflects prevailing currents in psychiatry and mental health systems nationwide and beyond. Recovery-based practice and the cultivation of rich therapeutic relationships have among the strongest evidence bases of any interventions for people with complex psychosis. Therefore, to fulfil its clinical potential, inpatient rehabilitation requires investment in the expertise, well-being, and availability of its frontline staff who make or break these relations. This must be facilitated by broader structural and institutional commitments.

To estimate the association between food insufficiency and mental health service utilisation in the USA during the COVID-19 pandemic.

Cross-sectional study. Multiple logistic regression models were used to estimate the associations between food insufficiency and mental health service utilisation.

US Census Household Pulse Survey data collected in October 2020.

Nationally representative sample of 68 611 US adults.

After adjusting for sociodemographic factors, experiencing food insufficiency was associated with higher odds of unmet mental health need (adjusted OR (AOR) 2·90; 95 % CI 2·46, 3·43), receiving mental health counselling or therapy (AOR 1·51; 95 % CI 1·24, 1·83) and psychotropic medication use (AOR 1·56; 95 % CI 1·35, 1·80). Anxiety and depression symptoms mediated most of the association between food insufficiency and unmet mental health need but not the associations between food insufficiency and either receiving mental health counselling/therapy or psychotropic medication use.

Clinicians should regularly screen patients for food insufficiency, especially in the wake of the COVID-19 pandemic. Expanding access to supplemental food programmes may help to mitigate the need for higher mental health service utilisation during the COVID-19 pandemic.

Psychotropic prescription rates continue to increase in the United States (USA). Few studies have investigated whether social-structural factors may play a role in psychotropic medication use independent of mental illness. Food insecurity is prevalent among people living with HIV in the USA and has been associated with poor mental health. We investigated whether food insecurity was associated with psychotropic medication use independent of the symptoms of depression and anxiety among women living with HIV in the USA.

We used cross-sectional data from the Women's Interagency HIV Study (WIHS), a nationwide cohort study. Food security (FS) was the primary explanatory variable, measured using the Household Food Security Survey Module. First, we used multivariable linear regressions to test whether FS was associated with symptoms of depression (Center for Epidemiologic Studies Depression [CESD] score), generalised anxiety disorder (GAD-7 score) and mental health-related quality of life (MOS-HIV Mental Health Summary score; MHS). Next, we examined associations of FS with the use of any psychotropic medications, including antidepressants, sedatives and antipsychotics, using multivariable logistic regressions adjusting for age, race/ethnicity, income, education and alcohol and substance use. In separate models, we additionally adjusted for symptoms of depression (CESD score) and anxiety (GAD-7 score).

Of the 905 women in the sample, two-thirds were African-American. Lower FS (i.e. worse food insecurity) was associated with greater symptoms of depression and anxiety in a dose–response relationship. For the psychotropic medication outcomes, marginal and low FS were associated with 2.06 (p < 0.001; 95% confidence interval [CI] = 1.36–3.13) and 1.99 (p < 0.01; 95% CI = 1.26–3.15) times higher odds of any psychotropic medication use, respectively, before adjusting for depression and anxiety. The association of very low FS with any psychotropic medication use was not statistically significant. A similar pattern was found for antidepressant and sedative use. After additionally adjusting for CESD and GAD-7 scores, marginal FS remained associated with 1.93 (p < 0.05; 95% CI = 1.16–3.19) times higher odds of any psychotropic medication use. Very low FS, conversely, was significantly associated with lower odds of antidepressant use (adjusted odds ratio = 0.42; p < 0.05; 95% CI = 0.19–0.96).

Marginal FS was associated with higher odds of using psychotropic medications independent of depression and anxiety, while very low FS was associated with lower odds. These complex findings may indicate that people experiencing very low FS face barriers to accessing mental health services, while those experiencing marginal FS who do access services are more likely to be prescribed psychotropic medications for distress arising from social and structural factors.