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BACKGROUND: Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological intervention. AIMS: We aimed to test the hypothesis that adding Social Recovery Therapy (SRT) to Enhanced Standard Care (ESC) would improve social recovery compared to ESC alone. METHODS: A pragmatic, assessor-blind, randomised controlled trial (PRODIGY: ISRCTN47998710, 29/11/2012) was conducted in three UK centres. Participants (N=270) were aged 16-25 years, with persistent social disability defined as under 30 weekly hours of structured activity and social impairment for six months plus, and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over nine months. The primary outcome was structured activity 15-months post-randomisation. RESULTS: One-hundred-and-thirty-two participants were randomised to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15-months increased by 11.1 hours for SRT plus ESC (M=22.4, SD=21.4) and 16.6 hours for ESC alone (M=27.7, (SD=26.5). There was no significant difference; treatment effect= -4.44, 95% confidence intervals -10.19—1.31, p=0.13. Missingness was consistently greater in ESC alone. CONCLUSIONS: We found no evidence for the superiority of SRT as adjunctive to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing adjunctive specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes. RELEVANCE STATEMENT: This important definitive trial focusses on an important and neglected group of young people with severe problems, who have not experienced an episode of psychosis, that are socially withdrawn. The results of the trial are surprising in showing no specific benefit for the candidate psychological therapy (Social Recovery Therapy). Instead, both the intervention and control group show very large gains in multiple markers of symptomatic and functional recovery, despite having severe and complex problems at outset. These results therefore show the tremendous potential for recovery in a group, often considered very difficult to engage and intractable, if comprehensive assessment and treatment is provided.

Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission.

Aim: Pathways to care (PtC) are a means of examining and understanding routes into mental health care. It is important to examine PtC in order to identify ways in which individuals access services, as well as highlighting barriers or delays to appropriate treatment. This study aimed to examine PtC experienced by young people accessing a pilot specialist youth mental health service (SYMHS) for those with non-psychotic, severe and complex mental health conditions in Norfolk, UK. Methods: Data were collected on a subsample of referrals accepted into the pilot SYMHS (n = 94) over a 12-month period. Duration and number of PtC were assessed using a semi-structured interview augmented by health record examination. Measures of premorbid history, symptoms and functioning were also collected. Results: The mean length of PtC was 3.74 years, and a mean of 5.53 pathways was experienced before appropriate services were accessed. Individuals were most likely to first seek help from their general practitioner followed by an educational provider. There were no associations between PtC and current symptoms, although individuals with a premorbid history of mental health problems experienced shorter PtC. There was a trend suggesting that individuals with long pathways had poorer functioning compared with those with shorter pathways. Conclusions: Pathways to care are variable in a group of young people presenting to mental health services. A majority of participants experienced ‘long pathways’, which may negatively impact on outcome. The results indicate the need to improve access to appropriate services by overcoming pathway barriers. Service implications are discussed.

Background: Young people who have social disability associated with severe and complex mental health problems are an important group in need of early intervention. Their problems often date back to childhood and become chronic at an early age. Without intervention, the long-term prognosis is often poor and the economic costs very large. There is a major gap in the provision of evidence-based interventions for this group, and therefore new approaches to detection and intervention are needed. This trial provides a definitive evaluation of a new approach to early intervention with young people with social disability and severe and complex mental health problems using social recovery therapy (SRT) over a period of 9 months to improve mental health and social recovery outcomes.\ud \ud Methods: This is a pragmatic, multi-centre, single blind, superiority randomised controlled trial. It is conducted in three sites in the UK: Sussex, Manchester and East Anglia. Participants are aged 16 to 25 and have both persistent and severe social disability (defined as engaged in less than 30 hours per week of structured activity) and severe and complex mental health problems. The target sample size is 270 participants, providing 135 participants in each trial arm. Participants are randomised 1:1 using a web-based randomisation system and allocated to either SRT plus optimised treatment as usual (enhanced standard care) or enhanced standard care alone. The primary outcome is time use, namely hours spent in structured activity per week at 15 months post-randomisation. Secondary outcomes assess typical mental health problems of the group, including subthreshold psychotic symptoms, negative symptoms, depression and anxiety. Time use, secondary outcomes and health economic measures are assessed at 9, 15 and 24 months post-randomisation. \ud \ud Discussion: This definitive trial will be the first to evaluate a novel psychological treatment for social disability and mental health problems in young people presenting with social disability and severe and complex non-psychotic mental health problems. The results will have important implications for policy and practice in the detection and early intervention for this group in mental health services.\ud \ud Trial registration: Trial Registry: International Standard Randomised Controlled Trial Number (ISRCTN) Registry. Trial Registration Number: ISRCTN47998710 (registered 29/11/2012).

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