PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (32)
 

Clipboard (0)
None

Select a Filter Below

Journals
more »
Year of Publication
more »
Document Types
author:(Helen gillaspy)
1.  Intentions and experiences of effective practice in mental health specific supported accommodation services: a qualitative interview study 
Background
Deinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients.
Methods
We interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis.
Results
There were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement.
Conclusions
The findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.
doi:10.1186/s12913-017-2411-0
PMCID: PMC5504783  PMID: 28693490
Supported Accommodation; Mental Health; Effective Practices; Goals; Intentions; Qualitative Study
2.  Assessing needs for psychiatric treatment in prisoners: 2. Met and unmet need 
Background
In a companion paper, we established high levels of psychiatric morbidity in prisoners (Bebbington et al. Soc Psychiatry Psychiatr Epidemiol, 2016). In the current report, we evaluate how this morbidity translates into specific needs for treatment and the consequent implications for services. Mental health treatment needs and the extent to which they had been met were assessed in a representative sample of prisoners in a male and a female prison in London (Pentonville and Holloway).
Methods
Prisoners were sampled at random in a sequential procedure based on the Local Inmate Data System. We targeted equal numbers of male remand, male sentenced, female remand, and female sentenced prisoners. Following structured assessment of psychosis, common mental disorders, PTSD, personality disorders and disorders of abuse, we used the MRC Needs for Care Assessment (NFCAS) to establish whether potential needs for care in ten areas of mental health functioning were met, unmet, or incapable of being met by services.
Results
Data on treatment experience were provided by 360 inmates. Eighty percent of females and 70% of males had at least one need for treatment. Over half (53.7%) of the needs of female prisoners were met, but only one third (36.5%) in males. Needs for medication were unmet in 32% of cases, while those for psychological treatment were unmet in 51%.
Conclusions
Unmet needs for mental health treatment and care were common in the two prisons. This has adverse consequences both for individual prisoners and for the effective functioning of the criminal justice system.
doi:10.1007/s00127-016-1313-5
PMCID: PMC5329078  PMID: 27878323
Prisoners; Psychiatric disorders; Psychosis; Needs for care; Treatment
3.  Assessing needs for psychiatric treatment in prisoners: 1. Prevalence of disorder 
Background
High levels of psychiatric morbidity in prisoners have important implications for services. Assessing Needs for Psychiatric Treatment in Prisoners is an evaluation of representative samples of prisoners in a male and a female prison in London. This paper reports on the prevalence of mental disorders. In a companion paper, we describe how this translates into mental health treatment needs and the extent to which they have been met.
Methods
Prisoners were randomly sampled in a sequential procedure based on the Local Inmate Data System. We interviewed roughly equal numbers from the following groups: male remand; male sentenced prisoners (Pentonville prison); and female remand; female sentenced prisoners (Holloway prison). Structured assessments were made of psychosis, common mental disorders, PTSD, personality disorder and substance abuse.
Results
We interviewed 197 male and 171 female prisoners. Psychiatric morbidity in male and female, sentenced and remand prisoners far exceeded in prevalence and severity than in equivalent general population surveys. In particular, 12% met criteria for psychosis; 53.8% for depressive disorders; 26.8% for anxiety disorders; 33.1% were dependent on alcohol and 57.1% on illegal drugs; 34.2% had some form of personality disorder; and 69.1% had two disorders or more. Moreover, in the year before imprisonment, 25.3% had used mental health services.
Conclusions
These rates of mental ill-health and their similarity in remand and sentenced prisoners indicate that diversion of people with mental health problems from the prison arm of the criminal justice system remains inadequate, with serious consequences for well-being and recidivism.
doi:10.1007/s00127-016-1311-7
PMCID: PMC5329095  PMID: 27878322
Prisoners; Epidemiology; Prevalence; Psychosis; Psychiatric disorders; Substance abuse; Needs for care
4.  Recovery-based staff training intervention within mental health rehabilitation units: a two-stage analysis using realistic evaluation principles and framework approach 
BMC Psychiatry  2016;16:292.
Background
Long-term change in recovery-based practice in mental health rehabilitation is a research priority.
Methods
We used a qualitative case study analysis using a blend of traditional ‘framework’ analysis and ‘realist’ approaches to carry out an evaluation of a recovery-focused staff training intervention within three purposively selected mental health rehabilitation units. We maximised the validity of the data by triangulating multiple data sources.
Results
We found that organisational culture and embedding of a change management programme in routine practice were reported as key influences in sustaining change in practice. The qualitative study generated 10 recommendations on how to achieve long-term change in practice including addressing pre-existing organisational issues and synergising concurrent change programmes.
Conclusions
We propose that a recovery-focused staff training intervention requires clear leadership and integration with any existing change management programmes to facilitate sustained improvements in routine practice.
doi:10.1186/s12888-016-0999-y
PMCID: PMC4989510  PMID: 27535830
5.  Are persistent delusions in schizophrenia associated with aberrant salience? 
Objective
It has been suggested that positive psychotic symptoms reflect ‘aberrant salience’. Previously we provided support for this hypothesis in first-episode schizophrenia patients, demonstrating that delusional symptoms were associated with aberrant reward processing, indexed by the Salience Attribution Test (SAT). Here we tested whether salience processing is abnormal in schizophrenia patients with long-standing treatment-refractory persistent delusions (TRS).
Method
Eighteen medicated TRS patients and 31 healthy volunteers completed the SAT, on which participants made a speeded response to earn money in the presence of cues. Each cue comprised two visual dimensions, colour and form. Reinforcement probability varied over one of these dimensions (task-relevant), but not the other (task-irrelevant).
Results
Participants responded significantly faster on high-probability relative to low-probability trials, representing implicit adaptive salience; this effect was intact in TRS patients. By contrast, TRS patients were impaired on the explicit adaptive salience measure, rating high-probability stimuli less likely to be associated with reward than controls. There was little evidence for elevated aberrant salience in the TRS group.
Conclusion
These findings do not support the hypothesis that persistent delusions are related to aberrant motivational salience processing in TRS patients. However, they do support the view that patients with schizophrenia have impaired reward learning.
doi:10.1016/j.scog.2016.04.002
PMCID: PMC4884769  PMID: 27284531
Schizophrenia; Psychosis; Delusions; Reinforcement; Behaviour
6.  Are persistent delusions in schizophrenia associated with aberrant salience? 
Objective
It has been suggested that positive psychotic symptoms reflect ‘aberrant salience’. Previously we provided support for this hypothesis in first-episode schizophrenia patients, demonstrating that delusional symptoms were associated with aberrant reward processing, indexed by the Salience Attribution Test (SAT). Here we tested whether salience processing is abnormal in schizophrenia patients with long-standing treatment-refractory persistent delusions (TRS).
Method
Eighteen medicated TRS patients and 31 healthy volunteers completed the SAT, on which participants made a speeded response to earn money in the presence of cues. Each cue comprised two visual dimensions, colour and form. Reinforcement probability varied over one of these dimensions (task-relevant), but not the other (task-irrelevant).
Results
Participants responded significantly faster on high-probability relative to low-probability trials, representing implicit adaptive salience; this effect was intact in TRS patients. By contrast, TRS patients were impaired on the explicit adaptive salience measure, rating high-probability stimuli less likely to be associated with reward than controls. There was little evidence for elevated aberrant salience in the TRS group.
Conclusion
These findings do not support the hypothesis that persistent delusions are related to aberrant motivational salience processing in TRS patients. However, they do support the view that patients with schizophrenia have impaired reward learning.
doi:10.1016/j.scog.2016.04.002
PMCID: PMC4884769  PMID: 27284531
Schizophrenia; Psychosis; Delusions; Reinforcement; Behaviour
7.  Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study 
BMC Psychiatry  2016;16:125.
Background
Co-occurring substance use increases the risk of hospitalisation in people with severe mental illness, whereas Assertive Community Treatment (ACT) generally reduces hospitalisation in patients with severe mental illness and high inpatient service use. Because the superiority of ACT over standard services amongst patients with problematic substance use is uncertain, the present study examined inpatient service use amongst patients with and without problematic substance use in the 2 years before and the 2 years after they enrolled into ACT teams.
Methods
This naturalistic observational study included 142 patients of 12 different ACT teams throughout Norway. The teams assessed the patients upon enrolment into ACT using clinician-rated and self-reported questionnaires. We obtained hospitalisation data from the Norwegian Patient Register for the 2 years before and the 2 years after enrolment into ACT. We used linear mixed models to assess changes in hospitalisation and to explore associations between problematic substance use and changes in hospitalisation, controlling for socio-demographic and clinical characteristics.
Results
A total of 84 (59 %) participants had problematic substance use upon enrolment into the ACT teams. In the 2 years after ACT enrolment both participants with and without problematic substance use experienced a reduction in total inpatient days. Those with problematic substance use also had fewer involuntary inpatient days. Exploratory analyses suggested that symptom severity and functioning level interacted with problematic substance use to influence change in total inpatient days.
Conclusion
These findings may suggest that ACT teams successfully support people with complex mental health problems in the community, including those with problematic substance use, and thereby contribute to a reduction in inpatient service use.
doi:10.1186/s12888-016-0826-5
PMCID: PMC4855443  PMID: 27145937
Assertive community treatment; Problematic substance use; Hospitalisation; Inpatient care
8.  Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England 
BMC Psychiatry  2016;16:95.
Background
Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10–20 % of all those with psychosis, they absorb 25–50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome.
Method
Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care.
Results
Across England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients’ social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00–1.08), and patients’ activity (OR 1.03, 95 % CI 1.01–1.05) and social skills (OR 1.13, 95 % CI 1.04–1.24) at recruitment.
Conclusion
Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients’ social skills and activities may further enhance the effectiveness of these services.
doi:10.1186/s12888-016-0797-6
PMCID: PMC4823891  PMID: 27056042
9.  Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study 
Background
Assertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT.
Methods
This naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics.
Results
When the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT.
Conclusion
The findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users.
doi:10.1186/s13033-016-0052-z
PMCID: PMC4772328  PMID: 26933446
Assertive community treatment; Hospitalization; High inpatient service use; Appropriate services
10.  An international comparison of the deinstitutionalisation of mental health care: Development and findings of the Mental Health Services Deinstitutionalisation Measure (MENDit) 
BMC Psychiatry  2016;16:54.
Background
Despite its inclusion as a key aspect of successful mental health care service provision by the World Health Organization, there exists a lack of consensus regarding the definition, key components and implementation of deinstitutionalisation. This lack of consensus has also contributed to subjectivity in assessments of countries’ progress towards deinstitutionalisation which act as a barrier to its evaluation and success. In order to provide for reliable within and cross country evaluations of the success of deinstitutionalisation we aimed to develop a quantitative measure of country-level progress towards deinstitutionalisation through the (1) identification of key markers of deinstitutionalisation; (2) development of an assessment tool based on the identified markers; (3) evaluation of the tool’s psychometric properties; and (4) comparison of progress towards deinstitutionalisation across Europe.
Methods
National care standards from 10 European countries and World Health Organization recommendations were used to identify items for the tool. A draft version was reviewed by an international expert panel and assessed for test-retest reliability and internal consistency. Once a final version had been agreed, progress towards deinstitutionalisation was assessed for 30 European countries. We used this opportunity to test convergent validity through comparison with local experts’ assessments. Country total as well as individual item scores were described and compared.
Results
The five-item Mental Health Services Deinstitutionalisation Measure (MENDit) is an objective tool with moderate to very good test-retest reliability (Kappa range: 0.46-1.00) and internal consistency (α = 0.70, 95 % CI 0.25, 0.92). A statistically significant difference between groups was found by one-way ANOVA (F(3,26) = 6.77, p = 0.002). Post-hoc testing found significant differences between MENDit scores of countries categorised as having advanced levels of deinstitutionalisation and not started or just started. Across Europe, MENDit scores suggest substantial variety in progress towards deinstitutionalisation.
Conclusions
The MENDit has good psychometric properties which support its use in research and as a benchmarking tool to measure national progress towards deinstitutionalisation by policy makers. Across Europe a high proportion of psychiatric beds are still located in psychiatric hospitals. Additionally, low numbers of mental health professionals in many countries may hinder further deinstitutionalisation. These findings corroborate previous mental health systems research and highlight some of the difficulties of deinstitutionalisation.
doi:10.1186/s12888-016-0762-4
PMCID: PMC4772656  PMID: 26926473
Deinstitutionalisation; Assessment; Mental health services; Validation
11.  Development and psychometric properties of the client’s assessment of treatment scale for supported accommodation (CAT-SA) 
BMC Psychiatry  2016;16:43.
Background
Patient-Reported Outcome Measures (PROMs) are important for evaluating mental health services. Yet, no specific PROM exists for the large and diverse mental health supported accommodation sector. We aimed to produce and validate a PROM specifically for supported accommodation services, by adapting the Client’s Assessment of Treatment Scale (CAT) and assessing its psychometric properties in a large sample.
Methods
Focus groups with service users in the three main types of mental health supported accommodation services in the United Kingdom (residential care, supported housing and floating outreach) were conducted to adapt the contents of the original CAT items and assess the acceptability of the modified scale (CAT-SA). The CAT-SA was then administered in a survey to service users across England. Internal consistency was assessed using Cronbach’s alpha. Convergent validity was tested through correlations with subjective quality of life and satisfaction with accommodation, as measured by the Manchester Short Assessment of Quality of Life (MANSA).
Results
All seven original items of the CAT were regarded as relevant to appraisals of mental health supported accommodation services, with only slight modifications to the wording required. In the survey, data were obtained from 618 clients. The internal consistency of the CAT-SA items was 0.89. Mean CAT-SA scores were correlated with the specific accommodation item on the MANSA (rs = 0.37, p˂.001).
Conclusions
The content of the CAT-SA has relevance to service users living in mental health supported accommodation. The findings from our large survey show that the CAT-SA is acceptable across different types of supported accommodation and suggest good psychometric properties. The CAT-SA appears a valid and easy to use PROM for service users in mental health supported accommodation services.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-016-0755-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-016-0755-3
PMCID: PMC4766675  PMID: 26911904
Patient Reported Outcome; Supported Accommodation; Treatment Satisfaction; Mental Health
12.  Living conditions and quality of care in residential units for people with long-term mental illness in Portugal – a cross-sectional study 
BMC Psychiatry  2016;16:34.
Background
As in most European countries, mental health care has shifted from large hospitals to smaller community based settings in Portugal. Our study objectives were to determine: a) the characteristics of users of mental health residential facilities in Portugal; b) the quality of care provided comparing community and hospital units; and c) to investigate associations between quality of care, service and service users’ characteristics and experiences of care.
Methods
All longer term mental health units in Portugal providing on-site staffed support for at least 12 h per day were assessed with the Quality Indicator for Rehabilitative Care (QuIRC), a standardised tool completed by the unit manager. The QuIRC rates seven domains of care (Living Environment, Therapeutic Environment, Treatments and Interventions, Self/Management and Autonomy, Recovery Based Practice, Social Inclusion, and Human Rights). A random sample of service users were interviewed using standardised measures of autonomy, experiences of care and quality of life.
Results
Most (60 %) of the 42 units were in Lisbon and surrounding districts with 50 % based in the community and 50 % in hospital settings. They had a mean of 11.5 beds. Service users (n = 278) were mainly men (66.2 %), with a diagnosis of schizophrenia (72.7 %), and a mean age of 49.4 years. Community units scored higher than hospital units on the Living Environment, Treatments and Interventions, and Self-Management and Autonomy domains of the QuIRC. Increased service user age was negatively associated with all but one domain. All QuIRC domains were positively associated with service users’ autonomy and experiences of care.
Conclusions
Investing in better quality, community based mental health facilities is associated with better outcomes for service users who require longer term support.
doi:10.1186/s12888-016-0743-7
PMCID: PMC4761132  PMID: 26897745
Long-term; Mental illness; Quality of care; Residential units
13.  Quality of care and its determinants in longer term mental health facilities across Europe; a cross-sectional analysis 
BMC Psychiatry  2016;16:31.
Background
The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients.
Methods
QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level.
Results
We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled.
Conclusions
This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group.
doi:10.1186/s12888-016-0737-5
PMCID: PMC4750356  PMID: 26868834
14.  Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial 
BMC Psychiatry  2015;15:209.
Background
We undertook a cluster randomised controlled trial to assess the effectiveness of a staff training intervention to improve patient engagement in activities in inpatient mental health rehabilitation units. Concurrently, we undertook a qualitative study to investigate the experiences of staff within the intervention units and the contextual issues that may have influenced the effectiveness of the intervention.
Method
We conducted focus groups with staff working in the inpatient units that received the intervention, sampled using a maximum variation strategy.
Results
The intervention was accepted by staff. However, the skills gained, and changes to the unit’s processes and structures that were agreed with the intervention team were not sustained after they left. The main reasons for this were a) external factors (economic recession, resource limitations); b) organisation level factors (lack of senior staff support; competing priorities); c) limitations of the intervention itself (length of intensive training period; reinforcement of skills).
Conclusion
This study illustrates some of the inter-related factors which operate at different levels within and outside of NHS organisations that may impact on the success of complex interventions. These factors need to be considered when designing interventions to ensure adequate buy-in from senior staff.
Trial registration
Current Controlled Trials ISRCTN25898179 (Registered 23 April 2010)
doi:10.1186/s12888-015-0592-9
PMCID: PMC4556020  PMID: 26328771
15.  Evaluation of a community awareness programme to reduce delays in referrals to early intervention services and enhance early detection of psychosis 
BMC Psychiatry  2015;15:98.
Background
Reducing treatment delay and coercive pathways to care are accepted aims for Early Intervention Services (EIS) for people experiencing first episode psychosis but how to achieve this is unclear. A one-year community awareness programme was implemented in a London EIS team, targeting staff in non-health service community organisations. The programme comprised psycho-educational workshops and EIS link workers, and offering direct referral routes to EIS. Its feasibility and its impact on duration of untreated psychosis and pathways to EIS were evaluated.
Methods
Evaluation comprised: pre and post questionnaires with workshop participants assessing knowledge and attitudes to psychosis and mental health services; and a comparison of new service users’ “service DUP”(time from first psychotic symptom to first contact with EIS) and pathways to care in the intervention year and preceding year. Focus groups sought stakeholders’ views regarding the benefits and limitations of the programme and what else might promote help-seeking.
Results
41 workshops at 36 community organisations were attended by 367 staff. 19 follow up workshops were conducted and 16 services were allocated an EIS link worker. Participants’ knowledge and attitudes to psychosis and attitudes to mental health services improved significantly following workshops. In the year of the intervention, only 6 of 110 new service users reached EIS directly via community organisations. For all new referrals accepted by EIS, in the intervention year compared to the previous year, there was no difference in mean or median service DUP. A clear impact on pathways to care could not be discerned. Stakeholders suggested that barriers to referral remained. These included: uncertainty about the signs of early psychosis, disengagement by young people when becoming unwell, and worries about stigma or coercive treatment from mental health services. More general, youth focused, mental health services were proposed.
Conclusions
The community awareness programme did not reduce treatment delays for people experiencing first episode psychosis. Further research is needed regarding effective means to reduce duration of untreated psychosis. Although EIS services are guided to promote access through community engagement, this may not be an effective use of their limited resources.
Trial registration
Current Controlled Trial ISRCTN98260910 Registered 19th May 2010.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-015-0485-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-015-0485-y
PMCID: PMC4424506  PMID: 25934413
Psychosis; Early intervention; Health education
16.  The ongoing need for local services for people with complex mental health problems 
The Psychiatric Bulletin  2014;38(6):257-259.
Despite developments in mental healthcare over recent decades, there remains a group of people with very complex needs who require lengthy admissions and high levels of support in the community on discharge. This is the group that mental health rehabilitation services focus on. In the context of contemporary mental health services that minimise in-patient lengths of stay, the needs of this group must not be overlooked. Providing a local, ‘whole system, integrated rehabilitation care pathway’ requires intelligent commissioning in order to avoid the social exclusion of this group to the ‘virtual asylum’ of out-of-area placements.
doi:10.1192/pb.bp.114.048470
PMCID: PMC4248159  PMID: 25505623
17.  Ten year outcomes of participants in the REACT (Randomised Evaluation of Assertive Community Treatment in North London) study 
BMC Psychiatry  2014;14:296.
Background
A previous randomised controlled trial that investigated Assertive Community Treatment (ACT) in the UK (the REACT Study) found no clinical advantage over usual care delivered by Community Mental Health Teams (CMHTs) at 18 and 36 month follow-ups. No studies have investigated long term clinical and social outcomes for patients receiving ACT.
Method
We investigated inpatient service use, social outcomes, service contact and adverse events for the 251 REACT study participants 10 years after randomisation through case note review. Data were analysed using regression models adjusted for original treatment group allocation and changes in treatment group.
Results
We found no statistically significant differences in outcomes by original treatment group over the 10 years. Those whose care remained with ACT, or transferred to ACT or forensic services, had more inpatient days over the 10 years (coefficient 223, 95% CI 83 to 363, p = 0.002) than those whose care remained with the CMHTs or were discharged to primary care. Being subject to a Community Treatment Order was associated with a greater chance of being under ACT at 10 year follow-up (OR 6.39, 95% CI 2.98 to 13.70, p <0.001).
Conclusions
The ACT teams in this study showed no clinical advantage over usual care provided by CMHTs at 10 year follow-up. We also found that the ACT teams accrued patients from the original study sample who had more complex needs than those who remained with or transferred to the CMHTs or primary care during this period. Further well conducted trials are needed to identify the most cost-effective approaches to supporting successful community living and optimum long term outcomes for this group.
doi:10.1186/s12888-014-0296-6
PMCID: PMC4210468  PMID: 25342641
Assertive Community Treatment; Long term outcomes
18.  The impact of psychosis on social inclusion and associated factors 
Background:
People with mental health problems are known to be socially excluded but the contribution of pre-morbid characteristics, symptoms and needs, and the impact on quality of life is unknown.
Aims:
To investigate change in social inclusion after the development of a psychotic Illness and factors associated with this.
Methods:
A cross-sectional community survey of people with psychosis was carried out in three areas of London. Five domains of social inclusion (social integration, consumption, access to services, productivity, political engagement) were assessed prior to the onset of illness and currently using the Social Inclusion Questionnaire User Experience. Quality of life, symptoms and needs were also assessed using standardized measures. Factors associated with change in social inclusion were investigated using multiple regression.
Results:
Productivity and social integration among the 67 participants reduced after the onset of psychosis. Older age at onset and longer duration of illness were associated with greater reduction in productivity. Less reduction in social integration was associated with greater quality of life. Participants reported barriers to social inclusion that were directly related to symptoms of their illness, low confidence and poor self-esteem.
Conclusions:
A greater focus on interventions that can facilitate the occupation and the social networks of people with psychosis is required. Interventions that tackle ‘self-stigma’ may also prove useful in mitigating the social exclusion experienced by people with psychosis.
doi:10.1177/0020764012471918
PMCID: PMC4107835  PMID: 23399990
Psychosis; social inclusion
19.  The Maristán stigma scale: a standardized international measure of the stigma of schizophrenia and other psychoses 
BMC Psychiatry  2014;14:182.
Background
People with schizophrenia face prejudice and discrimination from a number of sources including professionals and families. The degree of stigma perceived and experienced varies across cultures and communities. We aimed to develop a cross-cultural measure of the stigma perceived by people with schizophrenia.
Method
Items for the scale were developed from qualitative group interviews with people with schizophrenia in six countries. The scale was then applied in face-to-face interviews with 164 participants, 103 of which were repeated after 30 days. Principal Axis Factoring and Promax rotation evaluated the structure of the scale; Horn’s parallel combined with bootstrapping determined the number of factors; and intra-class correlation assessed test-retest reliability.
Results
The final scale has 31 items and four factors: informal social networks, socio-institutional, health professionals and self-stigma. Cronbach’s alpha was 0.84 for the Factor 1; 0.81 for Factor 2; 0.74 for Factor 3, and 0.75 for Factor 4. Correlation matrix among factors revealed that most were in the moderate range [0.31-0.49], with the strongest occurring between perception of stigma in the informal network and self-stigma and there was also a weaker correlation between stigma from health professionals and self-stigma. Test-retest reliability was highest for informal networks [ICC 0.76 [0.67 -0.83]] and self-stigma [ICC 0.74 [0.64-0.81]]. There were no significant differences in the scoring due to sex or age. Service users in Argentina had the highest scores in almost all dimensions.
Conclusions
The MARISTAN stigma scale is a reliable measure of the stigma of schizophrenia and related psychoses across several cultures. A confirmatory factor analysis is needed to assess the stability of its factor structure.
doi:10.1186/1471-244X-14-182
PMCID: PMC4074312  PMID: 24943228
Stigma; Questionnaire; Psychometrics; Rating scale schizophrenia
20.  Moderating factors for the effectiveness of group art therapy for schizophrenia: secondary analysis of data from the MATISSE randomised controlled trial 
Purpose
Although some studies suggest that art therapy may be useful in the treatment of negative symptoms of schizophrenia, a recent large trial of group art therapy found no clinical advantage over standard care, but the study population was heterogeneous and uptake of the intervention was poor. This study aimed to investigate whether art therapy was more effective for specific subgroups of patients.
Methods
Secondary analysis of data from a randomised controlled trial of group art therapy as an adjunctive treatment for schizophrenia (n = 140) versus standard care alone (n = 137). Positive and Negative Syndrome Scale scores at 12 months were compared between trial arms. Interaction between intervention effect and different subgroups, including those with more severe negative symptoms of schizophrenia, and those who expressed a preference for art therapy prior to randomisation, was tested using a linear mixed model.
Results
The clinical effectiveness of group art therapy did not significantly differ between participants with more or less severe negative symptoms [interaction for difference in PANSS = 1.7, 95 % CI (−8.6 to 12.1), P = 0.741], or between those who did and did not express a preference for art therapy [interaction = 3.9, 95 % CI (−6.7 to 14.5), P = 0.473]. None of the other exploratory subgroups suggested differences in intervention effect.
Conclusions
There was no evidence of greater improvement in clinical symptoms of schizophrenia for those with more severe negative symptoms or those with a preference for art therapy. Identification of patients with schizophrenia who may benefit most from group art therapy remains elusive.
doi:10.1007/s00127-014-0876-2
PMCID: PMC4201747  PMID: 24723218
Art therapy; Schizophrenia; Randomised controlled trial; Effect modifier; Subgroup analysis
21.  Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users’ engagement in activities 
BMC Psychiatry  2013;13:216.
Background
This study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this.
Methods/design
This study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users’ engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a “hands-on”, manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care.
Discussion
The study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).
doi:10.1186/1471-244X-13-216
PMCID: PMC3765675  PMID: 23981710
22.  Quality of Longer Term Mental Health Facilities in Europe: Validation of the Quality Indicator for Rehabilitative Care against Service Users’ Views 
PLoS ONE  2012;7(6):e38070.
Background
The Quality Indicator for Rehabilitative Care (QuIRC) is a staff rated, international toolkit that assesses care in longer term hospital and community based mental health facilities. The QuIRC was developed from review of the international literature, an international Delphi exercise with over 400 service users, practitioners, carers and advocates from ten European countries at different stages of deinstitutionalisation, and review of the care standards in these countries. It can be completed in under an hour by the facility manager and has robust content validity, acceptability and inter-rater reliability. In this study, we investigated the internal validity of the QuIRC. Our aim was to identify the QuIRC domains of care that independently predicted better service user experiences of care.
Method
At least 20 units providing longer term care for adults with severe mental illness were recruited in each of ten European countries. Service users completed standardised measures of their experiences of care, quality of life, autonomy and the unit’s therapeutic milieu. Unit managers completed the QuIRC. Multilevel modelling allowed analysis of associations between service user ratings as dependent variables with unit QuIRC domain ratings as independent variables.
Results
1750/2495 (70%) users and the managers of 213 units from across ten European countries participated. QuIRC ratings were positively associated with service users’ autonomy and experiences of care. Associations between QuIRC ratings and service users’ ratings of their quality of life and the unit’s therapeutic milieu were explained by service user characteristics (age, diagnosis and functioning). A hypothetical 10% increase in QuIRC rating resulted in a clinically meaningful improvement in autonomy.
Conclusions
Ratings of the quality of longer term mental health facilities made by service managers were positively associated with service users’ autonomy and experiences of care. Interventions that improve quality of care in these settings may promote service users’ autonomy.
doi:10.1371/journal.pone.0038070
PMCID: PMC3366953  PMID: 22675508
23.  Group art therapy as an adjunctive treatment for people with schizophrenia: multicentre pragmatic randomised trial 
The BMJ  2012;344:e846.
Objectives To evaluate the clinical effectiveness of group art therapy for people with schizophrenia and to test whether any benefits exceed those of an active control treatment.
Design Three arm, rater blinded, pragmatic, randomised controlled trial.
Setting Secondary care services across 15 sites in the United Kingdom.
Participants 417 people aged 18 or over, who had a diagnosis of schizophrenia and provided written informed consent to take part in the study.
Interventions Participants, stratified by site, were randomised to 12 months of weekly group art therapy plus standard care, 12 months of weekly activity groups plus standard care, or standard care alone. Art therapy and activity groups had up to eight members and lasted for 90 minutes. In art therapy, members were given access to a range of art materials and encouraged to use these to express themselves freely. Members of activity groups were offered various activities that did not involve use of art or craft materials and were encouraged to collectively select those they wanted to pursue.
Main outcome measures The primary outcomes were global functioning, measured using the global assessment of functioning scale, and mental health symptoms, measured using the positive and negative syndrome scale, 24 months after randomisation. Main secondary outcomes were levels of group attendance, social functioning, and satisfaction with care at 12 and 24 months.
Results 417 participants were assigned to either art therapy (n=140), activity groups (n=140), or standard care alone (n=137). Primary outcomes between the three study arms did not differ. The adjusted mean difference between art therapy and standard care at 24 months on the global assessment of functioning scale was −0.9 (95% confidence interval −3.8 to 2.1), and on the positive and negative syndrome scale was 0.7 (−3.1 to 4.6). Secondary outcomes did not differ between those referred to art therapy or those referred to standard care at 12 or 24 months.
Conclusions Referring people with established schizophrenia to group art therapy as delivered in this trial did not improve global functioning, mental health, or other health related outcomes.
Trial registration Current Controlled Trials ISRCTN46150447.
doi:10.1136/bmj.e846
PMCID: PMC3289714  PMID: 22374932
24.  Service user and carer experiences of seeking help for a first episode of psychosis: a UK qualitative study 
BMC Psychiatry  2011;11:157.
Background
Long duration of untreated psychosis (DUP) is associated with poor outcomes and low quality of life at first contact with mental health services. However, long DUP is common. In order to inform initiatives to reduce DUP, we investigated service users' and carers' experiences of the onset of psychosis and help-seeking in two multicultural, inner London boroughs and the roles of participants' social networks in their pathways to care.
Method
In-depth interviews were conducted with service users and carers from an early intervention service in North London, purposively sampled to achieve diversity in sociodemographic characteristics and DUP and to include service users in contact with community organisations during illness onset. Interviews covered respondents' understanding of and reaction to the onset of psychosis, their help-seeking attempts and the reactions of social networks and health services. Thematic analysis of interview transcripts was conducted.
Results
Multiple barriers to prompt treatment included not attributing problems to psychosis, worries about the stigma of mental illness and service contact, not knowing where to get help and unhelpful service responses. Help was often not sought until crisis point, despite considerable prior distress. The person experiencing symptoms was often the last to recognise them as mental illness. In an urban UK setting, where involved, workers in non-health community organisations were frequently willing to assist help-seeking but often lacked skills, time or knowledge to do so.
Conclusion
Even modest periods of untreated psychosis cause distress and disruption to individuals and their families. Early intervention services should prioritise early detection. Initiatives aimed at reducing DUP may succeed not by promoting swift service response alone, but also by targeting delays in initial help-seeking. Our study suggests that strategies for doing this may include addressing the stigma associated with psychosis and community education regarding symptoms and services, targeting not only young people developing illness but also a range of people in their networks, including staff in educational and community organisations. Initiatives to enhance the effective involvement of staff in community organisations working with young people in promoting help-seeking merit research.
doi:10.1186/1471-244X-11-157
PMCID: PMC3193166  PMID: 21961829
25.  The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems 
BMC Psychiatry  2011;11:35.
Background
Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted.
Method
The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion.
Results
The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care.
Conclusions
Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts.
doi:10.1186/1471-244X-11-35
PMCID: PMC3056767  PMID: 21362167

Results 1-25 (32)