Objective: Long-acting injectable antipsychotics (LAI-As) are a crucial treatment option for individuals with serious mental illness. However, due to the necessity of in-person administration of LAI-As, pandemics pose unique challenges for continuity of care in the population prescribed these medications. This project investigated the impact of the coronavirus disease 2019 (COVID-19) pandemic on LAI-A adherence at a Veterans Health Administration medical facility in the United States, as well as changes in LAI-A prescribing and administration practices during this period. Methods: Electronic health records were evaluated for 101 patients prescribed LAI-As. A subset of 13 patients also participated in an interview and rated subjective concerns about pandemic-related barriers to medication adherence. Results: Pandemic-related barriers to LAI-A adherence and/or changes to LAI-A medications were documented in 33% of the patients. Within-subjects comparison of an adherence metric computed from electronic health record data further suggested a somewhat higher incidence of missed or delayed LAI-A doses during the pandemic compared with before the pandemic. In contrast, only 2 of the 13 patients interviewed anticipated that pandemic-related concerns would interfere with medication adherence. Conclusions: The results of this study suggest that LAI-A access and adherence can be disrupted by pandemics and other public health emergencies but this finding may not generalize to other sites. As patients may not foresee the potential for disruption, psychiatric service providers may need to assist in proactively problem-solving barriers to access. Improved preparedness and additional safeguards against pandemic-related disruptions to LAI-A access and adherence may help mitigate adverse outcomes in the future. Identifying patients at elevated risk for such disruptions may help support these efforts.

It is this philosophical basis, not just psychiatric diagnosis and medicalisation as such, which needs to be fundamentally re-thought if we are not to end up with variations on the same unsatisfactory system. Modified versions such as the 'vulnerability-stress' or 'biopsychosocial' models still position social and relational factors as secondary to underlying biological causal malfunctions, and thus do not fully theorise distress as a meaningful, functional and understandable response to life circumstances.Drawing on relevant theoretical approaches, principles and practices are presented which allow us to see humans as active, purposeful agents, creating meaning and making choices in their lives, while at the same time subject to very real enabling and limiting factors, bodily, material, social and ideological. This has implications for service user/survivor and carer voices and views, for culturally appropriate perspectives on manifestations of distress, and more widely, for ethics, values and social justice. In relation to the aims of the project, the implication is that patterns underpinning individual and group experiences of distress will be inseparable from their material, environmental, socio-economic and cultural contexts, and that alternatives to diagnosis need to recognise the centrality of meaning, narrative, agency and subjective experience.Chapter 3 picks up these themes by examining meaning and narrative in more detail. Personal meanings are shaped by social and cultural discourses, which themselves arise within wider social structures and socioeconomic contexts. These in turn are based on particular assumptions about human nature and behaviour. Judgements about who is deemed to be 'mad' are inevitably, to some extent, based on implicit norms about what are acceptable ways of thinking, feeling and behaving in a given society. This includes norms about gender roles, class and 'race', such that those whose behaviour and experiences do not fit the implicit parameters -either by falling short of expectations, or by over-fulfilling them -are more likely to attract a diagnosis. Further, it is suggested that lived experiences of distress, particularly in industrialised societies, are shaped by the more deep-rooted assumptions we have outlined above. Most profound of all are our core assumptions about personhood -what we mean by the 'self', and the relationship between self, others and the material and natural world. One implication is that, as cross cultural studies show, there are not, and cannot be, universal categories of emotional distress.