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1.  Modelling the Interplay between Childhood and Adult Adversity in Pathways to Psychosis 
Psychological medicine  2013;44(2):407-419.
Background
There is evidence that a range of socio-environmental exposures are associated with an increased risk of psychosis. However, despite the fact that such factors probably combine in complex ways to increase risk, the majority of studies have tended to consider each exposure separately. In light of this, we sought to extend previous analyses of data from the ÆSOP study on childhood and adult markers of disadvantage to examine how they combine to increase risk of psychosis, testing both mediation (path) models and synergistic effects.
Method
All patients with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK (n = 390) and a series of community controls (n = 391) were included in the ÆSOP study. Data relating to clinical and social variables, including parental separation and loss, education and adult disadvantage, were collected from cases and controls.
Results
There was evidence that the effect of separation from, but not death of, a parent in childhood on risk of psychosis was partially mediated through subsequent poor educational attainment (no qualifications), adult social disadvantage and, to a lesser degree, low self-esteem. In addition, there was strong evidence that separation from, but not death of, a parent combined synergistically with subsequent disadvantage to increase risk. These effects held for all ethnic groups in the sample.
Conclusions
Exposure to childhood and adult disadvantage may combine in complex ways to push some individuals along a predominantly socio-developmental pathway to psychosis.
doi:10.1017/S0033291713000767
PMCID: PMC4081841  PMID: 23590972
2.  VOICE: Developing a new measure of service users’ perceptions of inpatient care, using a participatory methodology 
Background
Service users express dissatisfaction with inpatient care and their concerns revolve around staff interactions, involvement in treatment decisions, the availability of activities and safety. Traditionally, satisfaction with acute care has been assessed using measures designed by clinicians or academics.
Aims
To develop a patient-reported outcome measure of perceptions of acute care. An innovative participatory methodology was used to involve services users throughout the research process.
Method
A total of 397 participants were recruited for the study. Focus groups of service users were convened to discuss their experiences and views of acute care. Service user researchers constructed a measure from the qualitative data, which was validated by expert panels of service users and tested for its psychometric properties.
Results
Views on Inpatient Care (VOICE) is easy to understand and complete and therefore is suitable for use by service users while in hospital. The 19-item measure has good validity and internal and test-retest reliability. Service users who have been compulsorily admitted have significantly worse perceptions of the inpatient environment.
Conclusions
A participatory methodology has been used to generate a self-report questionnaire measuring service users’ perceptions of acute care. VOICE encompasses the issues that service users consider most important and has strong psychometric properties.
doi:10.3109/09638237.2011.629240
PMCID: PMC4018995  PMID: 22257131
service users’ perceptions; participatory methodology; service user involvement; acute care; inpatient services
4.  Inpatient care 50 years after the process of deinstitutionalisation 
Purpose
Throughout the past 50 years mental health services have aimed to provide and improve high quality inpatient care. It is not clear whether there has been improvement as service users and nursing staff have both expressed frustration at the lack of therapeutic activities. In particular, it may be that the changing levels of symptoms over the past 50 years may affect engagement with ward activities.
Methods
Eight wards in a health care trust in London serving an inner city and urban populations participated. Data were collected on participation in activities and 116 service users’ perceptions of acute care as well as clinical factors.
Results
Less time was spent participating in activities today than 50 years ago, while one quarter of service users reported taking part in no activities at all. Uptake of activities was related to more positive service user perceptions of the wards. Symptom severity did not impact the frequency of participation in activities, although those who took part in no activities at all had higher negative symptoms scores.
Conclusions
Service users’ uptake of activities was not related to the severity of their illness. This belies the belief that the acutely ill cannot take part in meaningful activities. This study supports the view that more therapeutic activities could be taken up by the acutely ill and are in fact appreciated.
doi:10.1007/s00127-013-0788-6
PMCID: PMC3969806  PMID: 24213523
Acute; Inpatient; Psychiatric; Service users; Activities
5.  Study to assess the effect of a structured communication approach on quality of life in secure mental health settings (Comquol): study protocol for a pilot cluster randomized trial 
Trials  2013;14:257.
Background
Forensic mental health services have largely ignored examining patients’ views on the nature of the services offered to them. A structured communication approach (DIALOG) has been developed with the aim of placing the patient’s perspective on their care at the heart of the discussions between patients and clinicians. The effectiveness of the structured communication approach in community mental health services has been demonstrated, but no trial has taken place in a secure psychiatric setting. This pilot study is evaluating a 6-month intervention combining DIALOG with principles of solution-focused therapy on quality of life in medium-secure settings.
Methods and design
A cluster randomized controlled trial design is being employed to conduct a 36-month pilot study. Participants are recruited from six medium-secure inpatient services, with 48 patients in the intervention group and 48 in the control group. The intervention uses a structured communication approach. It comprises six meetings between patient and nurse held monthly over a 6-month period. During each meeting, patients rate their satisfaction with a range of life and treatment domains with responses displayed on a tablet. The rating is followed by a discussion of how to improve the current situation in those domains identified by the patient. Assessments take place prior to the intervention (baseline), at 6 months (postintervention) and at 12 months (follow-up). The primary outcome is the patient’s self-reported quality of life.
Discussion
This study aims to (1) establish the feasibility of the trial design as the basis for determining the viability of a large full-scale trial, (2) determine the variability of the outcomes of interest (quality of life, levels of satisfaction, disturbance, ward climate and engagement with services), (3) estimate the costs of the intervention and (4) refine the intervention following the outcome of the study based upon the experiences of the nurses and patients. The intervention allows patients to have a greater say in how they are treated and targets care in areas that patients identify as important to them. It is intended to establish systems that support meaningful patient and caregiver involvement and participation.
Trial registration
Current Controlled Trials, ISRCTN34145189
doi:10.1186/1745-6215-14-257
PMCID: PMC3765869  PMID: 23947774
Comquol; DIALOG; Forensic; Mental health; Quality of life; Solution-focused brief therapy
6.  Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study 
BMC Psychiatry  2013;13:167.
Background
Recovery has become an increasingly prominent concept in mental health policy internationally. However, there is a lack of guidance regarding organisational transformation towards a recovery orientation. This study evaluated the implementation of recovery-orientated practice through training across a system of mental health services.
Methods
The intervention comprised four full-day workshops and an in-team half-day session on supporting recovery. It was offered to 383 staff in 22 multidisciplinary community and rehabilitation teams providing mental health services across two contiguous regions. A quasi-experimental design was used for evaluation, comparing behavioural intent with staff from a third contiguous region. Behavioural intent was rated by coding points of action on the care plans of a random sample of 700 patients (400 intervention, 300 control), before and three months after the intervention. Action points were coded for (a) focus of action, using predetermined categories of care; and (b) responsibility for action. Qualitative inquiry was used to explore staff understanding of recovery, implementation in services and the wider system, and the perceived impact of the intervention. Semi-structured interviews were conducted with 16 intervention group team leaders post-training and an inductive thematic analysis undertaken.
Results
A total of 342 (89%) staff received the intervention. Care plans of patients in the intervention group had significantly more changes with evidence of change in the content of patient’s care plans (OR 10.94. 95% CI 7.01-17.07) and the attributed responsibility for the actions detailed (OR 2.95, 95% CI 1.68-5.18). Nine themes emerged from the qualitative analysis split into two superordinate categories. ‘Recovery, individual and practice’, describes the perception and provision of recovery orientated care by individuals and at a team level. It includes themes on care provision, the role of hope, language of recovery, ownership and multidisciplinarity. ‘Systemic implementation’, describes organizational implementation and includes themes on hierarchy and role definition, training approaches, measures of recovery and resources.
Conclusions
Training can provide an important mechanism for instigating change in promoting recovery-orientated practice. However, the challenge of systemically implementing recovery approaches requires further consideration of the conceptual elements of recovery, its measurement, and maximising and demonstrating organizational commitment.
doi:10.1186/1471-244X-13-167
PMCID: PMC3683325  PMID: 23764121
Recovery; Mental health; Health services; Implementation; Organizational change
7.  Evaluation of Greek psychiatric reforms: methodological issues 
Over the last three decades significant efforts have been made in many European countries to move away from a mental health system dominated by institutional care towards one whereby the main emphasis is on providing care and support within the community. Although the time of starting the reforms, their pace, the political context, and the exact objectives varies substantially across Europe, practically all countries have been undergoing such major reforms aimed at establishing services in the community to replace institutional based care. Each country makes its own decisions about the necessary mental health services taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture. These factors become an integral element of a national mental health policy and action plan, closely linked with national public health strategies.
Greece has been modernizing an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. This article describes the methodology used for the evaluation of the Psychargos programme of the mental health reforms in Greece. Various forms of community-based mental health services have been developed including supported living facilities, community mental health centres and employment opportunities.
doi:10.1186/1752-4458-7-11
PMCID: PMC3622561  PMID: 23537115
Evaluation; Mental health reforms; Community mental health services; Greece
8.  Forced residential mobility and social support: impacts on psychiatric disorders among Somali migrants 
Background
Somali migrants fleeing the civil war in their country face punishing journeys, the loss of homes, possessions, and bereavement. On arrival in the host country they encounter poverty, hostility, and residential instability which may also undermine their mental health.
Methods
An in-depth and semi-structured interview was used to gather detailed accommodation histories for a five year period from 142 Somali migrants recruited in community venues and primary care. Post-codes were verified and geo-mapped to calculate characteristics of residential location including deprivation indices, the number of moves and the distances between residential moves. We asked about the reasons for changing accommodation, perceived discrimination, asylum status, traumatic experiences, social support, employment and demographic factors. These factors were assessed alongside characteristics of residential mobility as correlates of ICD-10 psychiatric disorders.
Results
Those who were forced to move homes were more likely to have an ICD-10 psychiatric disorder (OR = 2.64, 1.16-5.98, p = 0.02) compared with those moving through their own choice. A lower risk of psychiatric disorders was found for people with larger friendship networks (0.35, 0.14-0.84, p = 0.02), for those with more confiding emotional support (0.42, 0.18-1.0, p = 0.05), and for those who had not moved during the study period (OR = 0.21, 0.07-0.62, p = 0.01).
Conclusions
Forced residential mobility is a risk factor for psychiatric disorder; social support may contribute to resilience against psychiatric disorders associated with residential mobility.
doi:10.1186/1472-698X-12-4
PMCID: PMC3384470  PMID: 22510245
9.  Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial 
Objectives To evaluate the effectiveness of integrated motivational interviewing and cognitive behavioural therapy in addition to standard care for patients with psychosis and a comorbid substance use problem.
Design Two centre, open, rater blind randomised controlled trial.
Setting Secondary care in the United Kingdom.
Participants 327 patients with a clinical diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and a diagnosis of dependence on or misuse of drugs, alcohol, or both according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
Intervention The intervention was integrated motivational interviewing and cognitive behavioural therapy plus standard care, which was compared with standard care alone. Phase one of therapy—“motivation building”—concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two—“action”—supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year.
Main outcome measures The primary outcome was death from any cause or admission to hospital in the 12 months after completion of therapy. Secondary outcomes were frequency and amount of substance use (assessed using the timeline followback method), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, and global assessment of functioning and deliberate self harm at 12 and 24 months, with additional timeline followback assessments at 6 and 18 months. Analysis was by intention to treat and robust treatment effect estimates were produced.
Results 327 participants were randomly allocated to either the intervention (n=164) or treatment as usual (n=163). At 24 months, 326 (99.7%) were assessed on the primary outcome and 246 (75.2%) on the main secondary outcomes. Treatment had no beneficial effect on hospital admissions or death during follow-up, with 23.3% (38/163) of the therapy group and 20.2% (33/163) of controls deceased or admitted (adjusted odds ratio 1.16, 95% confidence interval 0.68 to 1.99; P=0.579). Therapy had no effect on the frequency of substance use or the perceived negative consequences of misuse, but did have a statistically significant effect on amount used per substance using day (adjusted ORs for main substance 1.50, 95% CI 1.08 to 2.09; P=0.016; and all substances 1.48, 95% CI 1.07 to 2.05; P=0.017). Treatment had a statistically significant effect on readiness to change use at 12 months (adjusted OR 2.05, 95% CI 1.26 to 3.31; P=0.004) that was not maintained at 24 months (0.78, 95% CI 0.48 to 1.28; P=0.320). There were no effects of treatment on clinical outcomes such as relapses, psychotic symptoms, functioning, and self harm.
Conclusions Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and substance misuse do not improve outcome in terms of hospitalisation, symptom outcomes, or functioning. This approach does reduce the amount of substance used for at least one year after completion of therapy.
Trial registration Current Controlled Trials: ISRCTN14404480.
doi:10.1136/bmj.c6325
PMCID: PMC2991241  PMID: 21106618
10.  Psychological symptoms in women in a primary care setting in Tamil Nadu 
Indian Journal of Psychiatry  2005;47(4):229-232.
Background:
Common mental disorders, especially depression, are likely to increase as a result of globalization and industrialization and it is likely that the resultant burden of care will increase proportionately. Women have a higher prevalence of depression and also carry the burden of caring for the affected individuals.
Aim:
To study the psychological symptoms with possible common mental disorders in a primary care setting.
Methods:
One hundred two women of Tamil ethnicity were approached to take part in answering the Self-Report Questionnaire (SRQ). The mean age of cases and non-cases were 39 years and 33 years, respectively.
Results:
Nearly three-fifths scored above the cut-off point. Age, physical illness and chronic pain were found to be important factors in the genesis of depression in particular.
Conclusion:
These findings have major implications for any preventative or intervention strategies.
doi:10.4103/0019-5545.43060
PMCID: PMC2921141  PMID: 20711313
Psychological symptoms; common mental disorders; Self-Report Questionnaire (SRQ)
11.  Exploratory cluster randomised controlled trial of shared care development for long-term mental illness. 
BACKGROUND: Primary care clinicians have a considerable amount of contact with patients suffering from long-term mental illness. The United Kingdom's National Health Service now requires general practices to contribute more systematically to care for this group of patients. AIMS: To determine the effects of Mental Health Link, a facilitation-based quality improvement programme designed to improve communication between the teams and systems of care within general practice. Design of study: Exploratory cluster randomised controlled trial. SETTING: Twenty-three urban general practices and associated community mental health teams. METHOD: Practices were randomised to service development as usual or to the Mental Health Link programme. Questionnaires and an audit of notes assessed 335 patients' satisfaction, unmet need, mental health status, processes of mental and physical care, and general practitioners' satisfaction with services and beliefs about service development. Service use and intervention costs were also measured. RESULTS: There were no significant differences in patients' perception of their unmet need, satisfaction or general health. Intervention patients had fewer psychiatric relapses than control patients (mean = 0.39 versus 0.71, respectively, P = 0.02) but there were no differences in documented processes of care. Intervention practitioners were more satisfied and services improved significantly for intervention practices. There was an additional mean direct cost of pound 63 per patient with long-term mental illness for the intervention compared with the control. CONCLUSION: Significant differences were seen in relapse rates and practitioner satisfaction. Improvements in service development did not translate into documented improvements in care. This could be explained by the intervention working via the improvements in informal shared care developed through better link working. This type of facilitated intervention tailored to context has the potential to improve care and interface working.
PMCID: PMC1314850  PMID: 15113492
13.  The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis 
BMJ : British Medical Journal  2004;329(7474):1067.
Objective To evaluate the effectiveness of a service for early psychosis.
Design Randomised controlled clinical trial.
Setting Community mental health teams in one London borough.
Participants 144 people aged 16-40 years presenting to mental health services for the first or second time with non-organic, non-affective psychosis.
Interventions Assertive outreach with evidence based biopsychosocial interventions (specialised care group) and standard care (control group) delivered by community mental health teams.
Primary outcome measures Rates of relapse and readmission to hospital.
Results Compared with patients in the standard care group, those in the specialised care group were less likely to relapse (odds ratio 0.46, 95% confidence interval 0.22 to 0.97), were readmitted fewer times (β 0.39, 0.10 to 0.68), and were less likely to drop out of the study (odds ratio 0.35, 0.15 to 0.81). When rates were adjusted for sex, previous psychotic episode, and ethnicity, the difference in relapse was no longer significant (odds ratio 0.55, 0.24 to 1.26); only total number of readmissions (β 0.36, 0.04 to 0.66) and dropout rates (β 0.28, 0.12 to 0.73) remained significant.
Conclusions Limited evidence shows that a team delivering specialised care for patients with early psychosis is superior to standard care for maintaining contact with professionals and for reducing readmissions to hospital. No firm conclusions can, however, be drawn owing to the modest sample size.
doi:10.1136/bmj.38246.594873.7C
PMCID: PMC526115  PMID: 15485934

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