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Purpose: The COVID-19 pandemic has potential to disrupt and burden the mental health care system, and to magnify inequalities experienced by mental health service users., Methods: We investigated staff reports regarding the impact of the COVID-19 pandemic in its early weeks on mental health care and mental health service users in the UK using a mixed methods online survey. Recruitment channels included professional associations and networks, charities, and social media. Quantitative findings were reported with descriptive statistics, and content analysis conducted for qualitative data., Results: 2,180 staff from a range of sectors, professions, and specialties participated. Immediate infection control concerns were highly salient for inpatient staff, new ways of working for community staff. Multiple rapid adaptations and innovations in response to the crisis were described, especially remote working. This was cautiously welcomed but found successful in only some clinical situations. Staff had specific concerns about many groups of service users, including people whose conditions are exacerbated by pandemic anxieties and social disruptions; people experiencing loneliness, domestic abuse and family conflict; those unable to understand and follow social distancing requirements; and those who cannot engage with remote care., Conclusion: This overview of staff concerns and experiences in the early COVID-19 pandemic suggests directions for further research and service development: we suggest that how to combine infection control and a therapeutic environment in hospital, and how to achieve effective and targeted tele-health implementation in the community, should be priorities. The limitations of our convenience sample must be noted.

Purpose: In England, community mental health rehabilitation teams play a major role in supporting people with complex mental health needs to progress from inpatient to community settings and from more to less supported accommodation. We aimed to conduct the first study to investigate longitudinal outcomes for users of a community rehabilitation team and identify service user characteristics associated with successful progress along the rehabilitation pathway., Methods: We used routinely collected clinical outcome data relating to all 193 users of a community rehabilitation team in inner London, transferred to the team between June 2013 and May 2018, with a cut-off data-collection date of 20th June 2019. We estimated the proportion who moved on to more independent accommodation successfully, with no breakdown in the placement. We conducted multivariable Cox proportional hazard regression to investigate associations between service user characteristics at transfer and successful move-on., Results: Overall, 43/193 (23%) service users achieved successful move-on during a median follow-up of 51 months (IQR 32-63). This was more likely for those who were residing in more highly supported accommodation (HR 3.90; 95% CI 2.01-7.54) and those who had better functioning (HR 1.04, 95% CI 1.02-1.06) at transfer, while those with a serious physical health condition were less likely to achieve successful move-on (HR 0.44, 95% CI 0.21-0.95)., Conclusion: Most supported accommodation services aim to offer time-limited support, but most service users do not progress successfully to more independent accommodation within 4 years. Investment in interventions that improve functioning and physical health may facilitate successful move-on.

Background: Individuals with severe mental health problems are at risk of social exclusion, which may complicate their recovery. Mental health and social care staff have, until now, had no valid or reliable way of assessing their clients' social inclusion. The Social Inclusion Questionnaire User Experience (SInQUE) was developed to address this. It assesses five domains: social integration; productivity; consumption; access to services; and political engagement, in the year prior to first psychiatric admission (T1) and the year prior to interview (T2) from which a total score at each time point can be calculated., Aims: To establish the validity, reliability, and acceptability of the SInQUE in individuals with a broad range of psychiatric diagnoses receiving care from community mental health services and its utility for mental health staff., Method: Participants were 192 mental health service users with psychosis, personality disorder, or common mental disorder (e.g., depression, anxiety) who completed the SInQUE alongside other validated outcome measures. Test-retest reliability was assessed in a sub-sample of 30 participants and inter-rater reliability was assessed in 11 participants. SInQUE ratings of 28 participants were compared with those of a sibling with no experience of mental illness to account for shared socio-cultural factors. Acceptability and utility of the tool were assessed using completion rates and focus groups with staff., Results: The SInQUE demonstrated acceptable convergent validity. The total score and the Social Integration domain score were strongly correlated with quality of life, both in the full sample and in the three diagnostic groups. Discriminant validity and test-retest reliability were established across all domains, although the test-retest reliability on scores for the Service Access and Political Engagement domains prior to first admission to hospital (T1) was lower than other domains. Inter-rater reliability was excellent for all domains at T1 and T2., Conclusions: The component of the SInQUE that assesses current social inclusion has good psychometric properties and can be recommended for use by mental health staff.

Purpose: England and Italy are considered pioneers in the development of community mental health services. Both have implemented supported accommodation services for those with more complex needs, which can be broadly categorized into three main types with similar specification. The aim of this study was to compare the characteristics of these services and their users in England and Italy., Methods: Data from two cross-sectional surveys of supported accommodation services undertaken across England and in Verona, Italy (England-619 service users from 87 services; Verona-167 service users from 25 services) were compared., Results: Service users in the two samples had similar socio-demographic and clinical characteristics; most were male, unmarried and unemployed, with a primary diagnosis of schizophrenia or other psychosis and over 15 years contact with mental health services. Supported accommodation occupancy was high in both samples. The actual length of stay was greater than the expected length of stay for all three service types but overall turnover was similar between countries (p = 0.070). Across services, total needs and quality of life were higher for Italian compared to English service users (p < 0.001 for both) but, unmet needs were lower amongst English service users (p < 0.001). Around 40% in both samples moved to more independent accommodation successfully within 30 months., Conclusions: England and Italy have similar mental health supported accommodation pathways to assist those with more complex needs to gain skills for community living, but individuals tend to require longer than expected at each stage.

Purpose: To investigate to what extent mental health treatment needs are met in white and black and minority ethnic (BME) prisoners., Methods: Treatment needs of a random sample of male (n = 197) and female (n = 171) prisoners were assessed with standardised instruments. Interventions provided were confirmed through face-to-face interviews and case note review., Results: BME prisoners comprised 44% of participants. Treatment for depression, personality disorder and alcohol abuse was more often needed by White than BME prisoners. Needs were more frequently met in White than BME prisoners (48.5% vs 38.2%; p < 0.05), largely due to the delivery of psychological treatments., Conclusions: BME prisoners had fewer of their mental health needs met.

Purpose: This study aimed to assess the efficacy of a staff-training intervention to improve service users' engagement in activities and quality of care, by means of a cluster randomised controlled trial., Method: All residential units with at least 12-h a day staff support (n = 23) were invited to participate. Quality of care was assessed with the Quality Indicator for Rehabilitative Care (QuIRC) filled online by the unit's manager. Half the units (n = 12) were randomly assigned to continue providing treatment as usual, and half (n = 11) received a staff-training intervention that focused on skills for engaging service users in activities, with trainers working alongside staff to embed this learning in the service. The primary outcome was service users' level of activity (measured with the Time Use Diary), reassessed at 4 and 8 months. Secondary outcomes were the quality of care provided (QuIRC), and service users' quality of life (Manchester Short Assessment of Quality of Life) reassessed at 8 months. Generalized linear mixed effect models were used to assess the difference in outcomes between units in the two trial arms. The trial was registered with Current Controlled Trials (Ref NCT02366117)., Results: Knowledge acquired by the staff during the initial workshops increased significantly (p ≤ 0.01). However, the intervention and comparison units did not differ significantly in primary and secondary outcomes at either follow-up., Conclusions: The intervention increased the level of knowledge of staff without leading to an improvement in service users' engagement in activities, quality of life, or quality of care in the units.

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.

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.

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.

Objective: There have been few recent studies reporting on the outcomes for users of psychiatric rehabilitation services. This group has complex, longer-term mental health problems. We aimed to investigate 5-year outcomes for this group and identify factors associated with outcome., Method: Clinical outcome data on 141 users of a mental health rehabilitation service in inner London, UK, surveyed in 2005, were collected retrospectively 5 years later. Positive outcome was defined for those who were inpatients in 2005 as achieving and sustaining community discharge, and for those who were community patients, as progressing to and sustaining a less supported community placement. Negative outcome was defined as remaining in the same placement, moving to more supported placement or having a psychiatric admission., Results: Over 5 years, 17 (12 %) people died, 50 (40 %) had a positive outcome, 33 (27 %) remained in a placement with a similar level of support and 41 (38 %) moved to a more supported placement and/or had a psychiatric admission. Thirteen (10 %) people moved to independent accommodation and sustained their tenancy successfully. Those with a record of non-adherence with medication during the 5 years were more likely to have a negative outcome (OR 8.60, 95 % CI 3.41 to 21.70)., Conclusion: Adherence to medication is an important factor in facilitating successful community discharge for people with complex mental health problems who require psychiatric rehabilitation.

Background: The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants., Method: Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team., Results: CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction., Conclusions: The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.