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Background: People with serious mental illness (SMI) die 15-20 years earlier than the general population, principally from cardiovascular and respiratory disease. Under-recognition and under-treatment of the physical health needs of people with SMI is one of the biggest health inequalities in England. Despite growing policy attention, evidence suggests the mortality gap between people with and without SMI is widening. This thesis aimed to enhance understanding about factors affecting the quality of primary care for people with SMI. Methods Mixed methods. Qualitative: thematic analysis of semi-structured interviews provided new insights from patients and practitioners on the quality of primary care. Quantitative: a difference-in-differences approach used to estimate the effect of removal of financial incentives on the proportion of patients who had physical health checks (blood pressure/BMI/cholesterol/glucose) recorded in primary care. Using a process of triangulation, findings from contrasting paradigms were synthesised. Results Qualitative study: quality of care for people with SMI is inadequate. Patient and practitioner aspirations for continuity and patient-centred care, increasingly undermined by new models of care delivery; Quality and Outcomes Framework (QOF) regarded as having been detrimental by prioritising a biomedical box ticking agenda in favour of holistic care; and a breakdown in communication between primary care and mental health services further eroded quality of care. Quantitative study: each difference-in-differences estimate for indicators where financial incentives were removed, compared with blood pressure which remained incentivised, indicated a significant decrease (p<0.01) in the proportion of patients with health checks recorded: BMI (-14.6%), cholesterol (-9.8%) and glucose (-8.8%). Conclusion: Despite growing interest in addressing the mortality gap, policy has focused on a biomedical approach in attempts to extend life expectancy, at the expense of addressing what matters to patients: being able to enhance their daily functioning and quality of life, to enable them to live better with their condition.

Background: People with severe mental illness (SMI) experience significant inequalities in physical health and die on average 15-20 years earlier than the general population. To address this, physical health is now higher on the health policy and practice agenda. However, sexual health is significantly neglected within current UK health policy, and there is a paucity of research within the UK despite the international literature suggesting the sexual health of people with SMI is poor. Methods: A range of methods were employed to explore the intersection of SMI and sexual health in the UK. A systematic review was undertaken to examine whether adults with SMI are more likely to engage in behaviours associated with increased risk of blood borne viruses/sexually transmitted infections compared to those with no history of SMI. A feasibility study examined recruitment processes and, explored participant feedback on the acceptability of a sexual health interview. Qualitative interviews explored mental health professional’s (MHPs) views in relation to the sexual health and relationship needs of people with SMI. Lastly, secondary data analysis of survey data examined the acceptability and experiences of people with SMI in the UK who participated in the RESPECT study. Results: Within the UK context, this thesis provides evidence that it is acceptable to speak to the SMI population about their sexual health and behaviour as well as preliminary evidence that it is feasible to recruit people with SMI to research in this area. Priorities for policy include bringing the sexual health and relationship needs to the forefront of guidance to ensure MHPs are aware of the legitimacy of supporting their service users with this aspect of their physical health. Conclusions: The research within this thesis provides important evidence that it is acceptable to undertake sexual health and behaviour research in people with SMI in the UK.

Introduction: Social relationships are increasingly being acknowledged as determinants of wellbeing and health in later life. We know that people who feel lonely – i.e. who are unhappy about their relationships – or who are socially isolated – i.e. have few ties or contacts with others – are more likely to experience early death. Whether they are at greater risk of morbidity is unclear. Aim: This thesis examines whether loneliness and social isolation are risk factors for developing ill health, with a primary focus on incident cardiovascular disease (CVD). The aim is to gauge the potential health gain from tackling loneliness and social isolation. Methods: Four pieces of empirical research make up the main body of my thesis. First, I designed a novel framework for distinguishing between measures of loneliness and social isolation. I then systematically reviewed the evidence from longitudinal observational studies on loneliness, social isolation and incident CVD. I studied changes in loneliness and social isolation over time in the English Longitudinal Study of Ageing (ELSA), a cohort of adults aged over 50 years old. Finally, I investigated associations between loneliness and social isolation over time, and incident CVD. Results: My systematic review found that loneliness and social isolation were associated with a 29% increase in risk of incident coronary heart disease (relative risk: 1.29, 95% CI 1.04 to 1.59) and a 32% increase in risk of stroke (relative risk: 1.32, 95% CI 1.04 to 1.68). Among ELSA participants, patterns of social relationships varied substantially over time, both within and between individuals. In survival analyses of ELSA data, loneliness but not social isolation was identified as a risk factor for incident CVD. Conclusions: Weaker social relationships are risk factors for developing CVD. Intervening to tackle loneliness and social isolation has the potential to improve health outcomes in later life.

Background Depression is a common, disabling condition for which psychological treatments, in particular cognitive behavioural therapies are recommended. Promising results from randomised trials has renewed interest in behavioural therapy, which may be suitable for delivery by non-specialist therapists. Aims To deliver a phased research programme to examine the clinical and cost effectiveness of behavioural therapy for depressed adults, and in particular the suitability of the intervention for delivery by non specialists. Research design A systematic review and meta-analysis examined randomised trials of behavioural treatments for depression compared to controls or other psychotherapies. Data on symptom level, recovery/dropout rate and study level moderators (study quality, number of sessions, severity and level of training) were extracted and analysed. Based upon results of the meta-analysis a randomised controlled trial of clinical and cost effectiveness comparing BA delivered by non-specialist with treatment as usual in a primary care setting was conducted. Results Meta-Analysis: Seventeen randomised controlled trials including 1109 subjects were included. A meta-analysis of symptom level post-treatment showed behavioural therapies were superior to controls (SMD -0.70 CI -1.00 to -0.39, k=12, N= 459), brief psychotherapy (SMD -0.56 -1.0 to-0.12, k=3, N=166), supportive therapy (SMD -0.75 CI –1.37 to -0.14, k=2, N=45) and equal to cognitive behavioural therapy (SMD 0.08 CI -0.14 to 0.30, k=12, N=476). Randomised controlled trial: Intention to treat analyses indicated a difference in favour of BA of −15.79 (95% CI −24.55 to −7.02) on the Beck Depression Inventory-II, −11.12; (95% CI = −17.53 to −4.70), on the Work and Social Adjustment Scale and a 0.20 (95% CI 0.01 to 0.39) improvement in quality adjusted life year. An incremental cost effectiveness ratio of £5756 per QALY indicates with a 97% probability that BA delivered by non-specialists is more cost effective than usual primary care at a threshold value of £20,000. Conclusion Behavioural Activation is an effective psychological treatment for depression that appears suitable for delivery by non-specialists. Further research with larger sample sizes and longer follow up is required to expand on the findings reported in this thesis.