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Introduction:Dementia is a major public health concern but one that continues to be stigmatised. We examine lay knowledge of dementia and attitudes to people with dementia as potential precursors of public anxiety, focusing on the social characteristics associated with (a) the formation of these attitudes, and (b) the perception of the need for restriction and control for people with dementia.Methods:Analysis of the 2014 Northern Ireland Life and Times survey, which included questions on knowledge of, attitudes to and personal experience with dementia. We used (a) latent class analysis and (b) logistic regression to examine factors associated with respondent attitudes towards dementia.Results:Respondents (n = 1211) had relatively good general knowledge of dementia, but limited knowledge of specific risk factors. Negative perceptions of dementia were mitigated somewhat by personal contact. A high proportion of respondents felt that high levels of control were appropriate for people diagnosed with dementia, even at early stages of the disease.Conclusion:Personal antipathy to dementia was highly prevalent despite ongoing public campaigns to increase public awareness of developments in its prevention, treatment and consequent care pathways and hampering efforts to widen social inclusion. Fresh thinking and more resources may be needed to challenge persisting common misapprehension of the condition and the formation of entrenched stigma.

BackgroundResearch focused on mental health in sport has revealed a need to develop evidence-supported mental health practices that are sensitive to sport culture, particularly for non-elite athletes. A consensus statement was produced to assist effective mental health awareness in sport and guide programme implementation in this rapidly emerging field.MethodThe AGREE Reporting Checklist 2016 was used in two international expert consultation meetings, followed by two online surveys. Experts from 10 countries and over 30 organisations contributed.ResultsSix objectives were agreed: (1) to define mental health awareness and service implementation constructs for inclusion in programmes delivered in sporting environments; (2) to identify the need to develop and use valid measures that are developmentally appropriate for use in intervention studies with sporting populations, including measures of mental health that quantify symptom severity but also consider causal and mediating factors that go beyond pathology (ie, well-being and optimisation); (3) to provide guidance on the selection of appropriate models to inform intervention design, implementation and evaluation; (4) to determine minimal competencies of training for those involved in sport to support mental health, those experiencing mental illness and when to refer to mental health professionals; (5) to provide evidence-based guidance for selecting mental health awareness and implementation programmes in sport that acknowledge diversity and are quality assured; and (6) to identify the need for administrators, parents, officials, coaches, athletes and workers to establish important roles in the promotion of mental health in various sports settings.ConclusionThis article presents a consensus statement on recommended psychosocial and policy-related approaches to mental health awareness programmes in sport.

Aim Despite extensive use in mental health research and practice, limited evidence exists for the hypothesised unidimensional model of the Warwick-Edinburgh Mental Well-Being Scale in adolescents. Few studies have assessed competing Confirmatory Factor Analysis (CFA) models, and the instrument has yet to be assessed in younger adolescents in Northern Ireland, a jurisdiction characterised by high rates of mental illness. Subject and methods School pupils (n=1,673) aged 13-18 years (M = 14.87, SD = 1.16), including 1,036 females, 997 urban children, and 312 from lower socio-economic status, completed psychometric tests. Seven CFA models based on extant research were tested, including unidimensional, bi-factor, higher-order and clustered. Results Several models, including the default unidimensional model, did not achieve recommended CFA fit thresholds. Model 6 comprising one strong ‘general well-being’ factor and three residual factors (i.e., figuratively labelled: ‘Affective’, ‘Psychological Functioning’ and ‘Social Relationships’) was confirmed as the superior model. Most item variance was explained by the general factor, relative to residual factors. Conclusions Adolescents predominantly conceptualise well-being as a unitary construct that coexists with relatively weak affective, psychological and social relationship domains. Researchers and practitioners should foremost calculate a composite score of well-being, and if appropriate, explore sub-domains to supplement understanding of adolescent well-being.

To examine patterns of childhood adversity, their long-term consequences and the combined effect of different childhood adversity patterns as predictors of subsequent psychopathology. Secondary analysis of data from the US National Epidemiologic Survey on alcohol and related conditions. Using latent class analysis to identify childhood adversity profiles; and using multinomial logistic regression to validate and further explore these profiles with a range of associated demographic and household characteristics. Finally, confirmatory factor analysis substantiated initial latent class analysis findings by investigating a range of mental health diagnoses. Latent class analysis generated a three-class model of childhood adversity in which 60 % of participants were allocated to a low adversity class; 14 % to a global adversities class (reporting exposures for all the derived latent classes); and 26 % to a domestic emotional and physical abuse class (exposed to a range of childhood adversities). Confirmatory Factor analysis defined an internalising-externalising spectrum to represent lifetime reporting patterns of mental health disorders. Using logistic regression, both adversity groups showed specific gender and race/ethnicity differences, related family discord and increased psychopathology. We identified underlying patterns in the exposure to childhood adversity and associated mental health. These findings are informative in their description of the configuration of adversities, rather than focusing solely on the cumulative aspect of experience. Amelioration of longer-term negative consequences requires early identification of psychopathology risk factors that can inform protective and preventive interventions. This study highlights the utility of screening for childhood adversities when individuals present with symptoms of psychiatric disorders.

People with advanced dementia are frequently bed-bound, doubly incontinent and able to speak only a few words. Many reside in care homes and may often have complex needs requiring efficient and timely response by knowledgeable and compassionate staff. The aim of this study is to improve our understanding of health care professionals' attitudes and knowledge of the barriers to integrated care for people with advanced dementia. In-depth, interactive interviews conducted with 14 health care professionals including commissioners, care home managers, nurses and health care assistants in the UK. Barriers to care for people with advanced dementia are influenced by governmental and societal factors which contribute to challenging environments in care homes, poor morale amongst care staff and a fragmentation of health and social care at the end of life. Quality of care for people with dementia as they approach death may be improved by developing collaborative networks to foster improved relationships between health and social care services.

Very little is known about the sexual activities of psychiatric patients during their stay in hospital and beyond. In this article, we have explored how mental health professionals working within a forensic psychiatric unit construct the issue of patient sexuality in order to ascertain the range of sexual possibilities open to patients. Drawing on interviews with twenty four participants — psychiatrists and clinical psychologists (clinical staff), we examined how participants made sense of patient sexuality and their clinical judgments in relation to them. Using a thematic analysis, we were able to identify a number of relevant themes emerging, including a) what the limits of acceptable sexual behaviour were judged to be, b) discrimination against transgender and same sex relationships, c) vulnerability among female patients and therapeutic efficacy, and d) an abject fear of patient pregnancy. Furthermore, a general concern throughout was the putative professional conflict between the clinical and ward staff. Further discussion regarding the potential for clearer policy on patient sexuality and further training for professionals is developed in the final section.

ObjectivesTo assess the acceptability and use of a low-cost patient-held communication tool.DesignLongitudinal qualitative interviews at three time points over 18 months and document content analysis.SettingPrimary and community services.ParticipantsTwenty-eight dyads: People living with dementia in Northern Ireland and their informal carers.InterventionsA patient-held healthcare ‘passport’ for people living with dementia.Primary and secondary outcomesAcceptability and use of the passport—barriers and facilitators to successful engagement.ResultsThere was a qualified appreciation of the healthcare passport and a much more nuanced, individualistic or personalised approach to its desirability and use. How people perceive it and what they actually do with it are strongly determined by individual contexts, dementia stage and other health problems, social and family needs and capacities. We noted concerns about privacy and ambivalence about engaging with health professionals.ConclusionSuch tools may be of use but there is a need for demanding, thoughtful and nuanced programme delivery for future implementation in dementia care. The incentivisation and commitment of general practitioners is crucial. Altering the asymmetrical relationship between professionals and patients requires more extensive attention.

BackgroundThe 2011 Northern Ireland Census asked whether individuals considered themselves to have a ‘limiting long-term health problem or disability’. This question was followed by 11 questions as to the nature of the long-term (12+ months) functional impairment(s) people are experiencing (problems with: hearing, sight, communication, mobility, learning difficulties, mental health, pain, breathing, memory, chronic conditions or other conditions). ObjectivesThe purpose of this study was to assess in what way selfreported functional impairment and disability predicts all-cause mortality in older people (age 65+) while taking into account socio-economic and demographic variables. MethodThe sample includes all individuals in Northern Ireland above age 65 at the time of the Census (2011). Data from the Census was linked to mortality data from Northern Ireland for 33 months after the time of the Census. To assess patterns of selfreported functional impairment, latent class analysis was used to derive groups of individuals who reported similar patterns on the 11-item list of functional impairments. These patterns were used to predict subsequent mortality, while controlling for demographic and socio-economic background factors. FindingsPreliminary results indicate the presence of four classes of self-reported functional impairment which can be described as: 1) Low impairment, 2) Pain/Mobility problems, 3) Cognitive/ Mental impairments, 4) Sensory and mobility problems. Initial analyses indicate that these classes were associated with large differences in subsequent mortality. ConclusionsDisability and functional impairment questionnaires can be effective tools to describe observed differences in mortality.

Little is known about how patients with long-term eating disorders manage their clinical problems. We carried out a preliminary qualitative study (using Thematic Analysis) of patients with severe and enduring anorexia nervosa (SEED-AN) in which we undertook recorded interviews in eight participants whose conditions had lasted 20-40 years. We found 15 principle features in physical, psychological, social, family, occupational and treatment realms. Psychological and social realms were most affected. Severe physical problems were reported. They described feelings of unworthiness, frugality regarding money and obsessive time-keeping. Persisting with negligible social networks, participants described depression and hopelessness, while somehow achieving a sense of pride at their endurance and survival in spite of the eating disorder. They emphasized the importance of professional help in managing their care. The severe and enduring description, often reserved for people with psychotic illness, is appropriately applied to SEED-AN, which has major impacts in all realms.

Summary Background Mental health inpatient rehabilitation services focus on people with complex psychosis who have, for example, treatment-refractory symptoms, cognitive impairment, and severe negative symptoms, which impair functioning and require lengthy admission. Engagement in activities could lead to improvement in negative symptoms and function, but few trials have been done. We aimed to investigate the effectiveness of a staff training intervention to increase patients' engagement in activities. Methods We did a single-blind, two-arm, cluster-randomised controlled trial in 40 mental health inpatient rehabilitation units across England. Units were randomly allocated to either a manual-based staff training programme delivered by a small intervention team (intervention group, n=20) or standard care (control group, n=20). The primary outcome was patients' engagement in activities 12 months after randomisation, measured with the time use diary. With this measure, both the degree of engagement in an activity and its complexity are recorded four times a day for a week, rated on a scale of 0–4 for every period (maximum score of 112). Analysis was by intention-to-treat. Random-effects models were used to compare outcomes between study groups. Cost-effectiveness was assessed by combining service costs with the primary outcome. This study is registered with Current Controlled Trials (ISRCTN25898179). Findings Patients' engagement in activities did not differ between study groups (coefficient 1·44, 95% CI −1·35 to 4·24). An extra £101 was needed to achieve a 1% increase in patients' engagement in activities with the study intervention. Interpretation Our training intervention did not increase patients' engagement in activities after 12 months of follow-up. This failure could be attributable to inadequate implementation of the intervention, a high turnover of patients in the intervention units, competing priorities on staff time, high levels of patients' morbidity, and ceiling effects because of the high quality of standard care delivered. Further studies are needed to identify interventions that can improve outcomes for people with severe and complex psychosis. Funding National Institute for Health Research.

Background The aim of the current study was to conduct a systematic review determining the effect of sport-specific mental health awareness programs to improve mental health knowledge and help-seeking among sports coaches, athletes and officials. The second aim was to review the study quality and to report on the validity of measures that were used to determine the effectiveness of programs. Methods Sport-specific mental health awareness programs adopting an experimental or quasi-experimental design were included for synthesis. Six electronic databases were searched: PsycINFO, MEDLINE (OVID interface), Scopus, Cochrane, CINAHL and SPORTDiscus. Each database was searched from its year of inception to October 2016. Risk of bias was assessed using the Cochrane and QATSQ tools. Results Ten studies were included from the 1216 studies retrieved: four comprising coaches or service providers, one with officials, four with athletes, and one involved a combination of coaches and athletes. A range of outcomes was used to assess indices of mental health awareness and well-being. Mental health referral efficacy was improved in six studies, while three reported an increase in knowledge about mental health disorders. However, seven studies did not report effect sizes for their outcomes, limiting clinically meaningful interpretations. Furthermore, there was substantial heterogeneity and limited validity in the outcome measures of mental health knowledge and referral efficacy. Seven studies demonstrated a high risk of bias. Conclusions Further, well-designed controlled intervention studies are required. Researchers, practitioners and policy makers should adhere to available methodological guidance and apply the psychological theory of behaviour change when developing and evaluating complex interventions. Trial registration PROSPERO CRD42016040178 Electronic supplementary material The online version of this article (10.1186/s13643-017-0568-6) contains supplementary material, which is available to authorized users.

Background Many people with dementia die in nursing homes, but quality of care may be suboptimal. We developed the theory-driven ‘Compassion Intervention’ to enhance end-of-life care in advanced dementia. Objectives To (1) understand how the Intervention operated in nursing homes in different health economies; (2) collect preliminary outcome data and costs of an interdisciplinary care leader (ICL) to facilitate the Intervention; (3) check the Intervention caused no harm. Design A naturalistic feasibility study of Intervention implementation for 6 months. Settings Two nursing homes in northern London, UK. Participants Thirty residents with advanced dementia were assessed of whom nine were recruited for data collection; four of these residents’ family members were interviewed. Twenty-eight nursing home and external healthcare professionals participated in interviews at 7 (n=19), 11 (n=19) and 15 months (n=10). Intervention An ICL led two core Intervention components: (1) integrated, interdisciplinary assessment and care; (2) education and support for paid and family carers. Data collected Process and outcome data were collected. Symptoms were recorded monthly for recruited residents. Semistructured interviews were conducted at 7, 11 and 15 months with nursing home staff and external healthcare professionals and at 7 months with family carers. ICL hours were costed using Department of Health and Health Education England tariffs. Results Contextual differences were identified between sites: nursing home 2 had lower involvement with external healthcare services. Core components were implemented at both sites but multidisciplinary meetings were only established in nursing home 1. The Intervention prompted improvements in advance care planning, pain management and person-centred care; we observed no harm. Six-month ICL costs were £18 255. Conclusions Implementation was feasible to differing degrees across sites, dependent on context. Our data inform future testing to identify the Intervention’s effectiveness in improving end-of-life care in advanced dementia. Trial registration ClinicalTrials.gov:NCT02840318: Results

Background: The consensus that volunteering is associated with a lower mortality risk is derived from a body of observational studies and therefore vulnerable to uncontrolled or residual confounding. This potential limitation is likely to be particularly problematic for volunteers who, by definition, are self-selected and known to be significantly different from non-volunteers across a range of factors associated with better survival.Methods: This is a census-based record-linkage study of 308 733 married couples aged 25 and over, including 100 571 volunteers, with mortality follow-up for 33 months. We used a standard Cox model to examine whether mortality risk in the partners of volunteers was influenced by partner volunteering status—something expected if the effects of volunteering on mortality risk were due to shared household or behavioural characteristics.Results: Volunteers were general more affluent, better educated and more religious than their non-volunteering peers; they also had a lower mortality risk [hazard ratio (HR)adj = 0.78: 95% confidence interval (CI) = 0.71, 0.85 for males and HRadj = 0.77: 95% CI = 0.68, 0.88 for females]. However, amongst cohort members who were not volunteers, having a partner who was a volunteer was not associated with a mortality advantage (HRadj = 1.01: 95% CI = 0.92, 1.11 for men and HRadj = 1.00: 95% CI = 0.88, 1.13 women).Conclusions: This study provides further evidence that the lower mortality associated with volunteering is unlikely to be due to health selection or to residual confounding arising from unmeasured selection effects within households. It therefore increases the plausibility of a direct causal effect.

BackgroundThe health impacts of caregiving and volunteering are rarely studied concurrently, despite the potential for both synergies and conflicts. This population-based study examines the association of these activities on health and subsequent mortality. Method A census-based record linkage study of 244,429 people aged sixty-five and over, with cohort characteristics, caregiving and volunteering status, and presence of chronic health conditions derived from the Census returns. Mortality risk was assessed over the following forty-five months with adjustment for baseline characteristics. Results Caregivers and volunteers were individually more mobile than those undertaking neither activity; caregivers who also volunteered were more mobile than those who did not volunteer, but no less likely to suffer from poor mental health. Both caregiving and volunteering were separately associated with reduced mortality risk (HR=0.74: 95%CIs=0.71, 0.77 and HR=0.76: 0.73, 0.81 respectively); the lowest mortality was found amongst light caregivers who also volunteered (HR=0.53: 95%CIs 0.45, 0.62), compared to those engaged in neither. There was no evidence of a multiplicative effect of caregiving and volunteering at more intense levels of caregiving. ConclusionThere is a large overlap in caregiving and volunteering activities with complex associations with health status. There is some evidence that combining caregiving and volunteering activities, for those involved in less intense levels of caregiving, may be associated with lower mortality risk than associated with either activity alone. Further research is needed to understand which aspects of caregiving and volunteering are best and for whom and in which circumstances.

Faith-based organisations, especially those related to specific ethnic or migrant groups, are increasingly viewed by secular Western government agencies as potential collaborators in community health and welfare programmes. Although clergy are often called upon to provide mental health pastoral care, their response to such problems remains relatively unexamined. This paper examines how clergy working in multiethnic settings do not always have the answers that people want, or perhaps need, to problems of misfortune and suffering. In the UK these barriers can be attributed, generally, to a lack of training on mental health problems and minimal collaboration with health services. The current paper attempts to highlight the dilemmas of the established churches’ involvement in mental health care in the context of diversity. We explore the inability of established churches to accommodate African and other spiritual beliefs and practices related to the etiology and treatment of mental health problems.

Accessible summary A national survey of over 1000 people took place in Ireland in 2001, 2006 and again in 2011. In 2011, half the people in the survey thought that people with intellectual disability or autism had the right to sexual relationships. In 2011, one-third agreed that people with intellectual disability or autism should have children if they wished. People's attitudes towards people with intellectual disabilities were similar to their attitudes towards people with mental illness. More people in the survey agreed that people with physical or sensory disabilities had the right to have sexual relationships and have children compared with people with intellectual disability. People in the survey were more likely to agree with the right to sexual relationships for people with intellectual disabilities if they: ○ lived outside of Dublin; ○ were single; ○ had more people in their own social networks; ○ were comfortable living near people with intellectual disability. People need to know more about what people with intellectual disabilities hope for from relationships. People need to know more about the supports that are in place: ○ to help people with intellectual disabilities make choices about sexual relationships ○ to protect people with intellectual disabilities against abuse. Summary Limited progress has been made in supporting people with intellectual disabilities to form intimate relationships. A critical factor that has been rarely researched is the attitude of the general public which likely has a significant influence on public policy on this issue. Unique to Ireland, are the five-yearly national surveys commissioned by the National Disability Authority that recruit representative samples of over 1000 adult persons. On three occasions in the past 10 years, respondents were asked to rate their agreement that people with various disabilities and with mental health difficulties had the right to fulfilment through sexual relationships and to have children if they wished. Secondary analysis of the 2011 data set identified those persons who were more likely to be in agreement and also the concerns raised by respondents. The findings are discussed in relation to priorities for future research and actions needed to reduce the stigma associated with disability or mental ill health.

Objectives Despite growing research interest in spirituality and health, and recommendations on the importance of spiritual care in advanced cancer and palliative care, relationships between spiritual belief and psychological health near death remain unclear. We investigated (i) relationships between strength of spiritual beliefs and anxiety and depression, intake of psychotropic/analgesic medications and survival in patients with advanced disease; and (ii) whether the strength of spiritual belief changes as death approaches. Methods We conducted a prospective cohort study of 170 patients receiving palliative care at home, 97% of whom had a diagnosis of advanced cancer. Data on strength of spiritual beliefs (Beliefs and Values Scale [BVS]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), psychotropic/analgesic medications, daily functioning, global health and social support were collected at recruitment then 3 and 10 weeks later. Mortality data were collected up to 34 months after the first patient was recruited. Results Regression analysis showed a slight increase in strength of spiritual belief over time approaching statistical significance (+0.16 BVS points per week, 95% CI [−0.01, 0.33], p = 0.073). Belief was unrelated to anxiety and depression (−0.15 points decrease in HADS for 10 points increased in BVS (95% CI [−0.57, 0.27], p = 0.49) or consumption of psychotropic medication). There was a non-significant trend for decreasing analgesic prescription with increasing belief. Mortality was higher over 6 months in participants with lower belief at recruitment. Conclusion Results suggest that although religious and spiritual beliefs might increase marginally as death approaches, they do not affect levels of anxiety or depression in patients with advanced cancer. © 2013 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.

BackgroundCurrent health policy assumes better quality services lead to better outcomes.AimsTo investigate the relationship between quality of mental health rehabilitation services in England, local deprivation, service user characteristics and clinical outcomes.MethodStandardised tools were used to assess the quality of mental health rehabilitation units and service users' autonomy, quality of life, experiences of care and ratings of the therapeutic milieu. Multiple level modelling investigated relationships between service quality, service user characteristics and outcomes.ResultsA total of 52/60 (87%) National Health Service trusts participated, comprising 133 units and 739 service users. All aspects of service quality were positively associated with service users' autonomy, experiences of care and therapeutic milieu, but there was no association with quality of life.ConclusionsQuality of care is linked to better clinical outcomes in people with complex and longer-term mental health problems. Thus, investing in quality is likely to show real clinical gains.

Background: Stigma about mental illness continues to run deeply in most societies, creating considerable difficulties for patients and families. Previous research points to particularly strong stigmatising attitudes in Greek and Greek Cypriots (Triandis 1989). It is unclear whether these attitudes continue to be held by UK-born Greek Cypriots. Method: In an area of north London which contains a large Greek-Cypriot population, we compared the attitudes towards mental illness by first- and second-generation Greek Cypriots and those of white-English ethnicity. Seventy-nine white-English participants and 91 Greek Cypriots were interviewed using a snowballing method. We used the ‘Community Attitudes to Mental Illness scale’ (Taylor and Dear 1981) to measure attitudes to mental illness. In addition we used questions from Wolff et al. (1996c) to measure subjects' knowledge of mental illness and contact with people with mental health problems. Results: We found that Greek Cypriots had less contact with mentally ill people, were less knowledgeable about mental illness and hold more stigmatising views than their English participants. Contrary to our expectations, we found little difference in attitudes about mental illness held by first- and second-generation Greek Cypriots. Knowledge about mental illness was associated with a positive attitude towards people with mental health problems. Conclusions: Aggressive educational campaigns targeted at specific minority communities such as the Greek-Cypriot community are required to challenge the stigma attached to mental illness.

The gender-based nature of suicide-related behaviour is largely accepted. However, studies that report exclusively on female suicides are rare. Here we demonstrate how female suicide has effectively been 'othered' and appears incidental in studies which compare female and male behaviour. We highlight how recent studies of suicide have tended to be dominated by male-only approaches, which increasingly link issues of masculinity with male death by suicide. Drawing on data collected from the general practitioner and coroner's office, we then apply the sociological autopsy approach to a cohort of 78 deaths recorded as suicides in the UK between 2007 and 2009. By focusing on females in isolation from males, we demonstrate that, as in male-only suicide studies, it is similarly possible to draw out issues associated with the feminine identity, which can be linked to death by suicide. We find that bereavement, sexual violence and motherhood could all be linked to the lives and help-seeking of the females who died. In closing, we suggest that a reorientation towards sociological analytic approaches of female suicide may help to produce further reductions in the rate of female death by suicide. A Virtual Abstract of this paper can be found at: https://www.youtube.com/watch?v=a0w9KKMFdIQ.

BackgroundAlthough substance misuse is a key risk factor in suicide, relatively little is known about the relationship between lifetime misuse and misuse at the time of suicide.AimsTo examine the relationship between substance misuse and subsequent suicide.MethodLinkage of coroners' reports to primary care records for 403 suicides occurring over 2 years.ResultsWith alcohol misuse, 67% of the cohort had previously sought help for alcohol problems and 39% were intoxicated at the time of suicide. Regarding misuse of other substances, 54% of the cohort was tested. Almost one in four (38%) tested positive, defined as an excess of drugs over the prescribed therapeutic dosage and/or detection of illicit substances. Those tested were more likely to be young and have a history of drug misuse.ConclusionsA deeper understanding of the relationship between substance misuse and suicide could contribute to prevention initiatives. Furthermore, standardised toxicology screening processes would avoid diminishing the importance of psychosocial factors involved in suicide as a ‘cause of death’.

Background People with severe mental illness (PWSMI) die 15-20 years earlier than people in the general population and this is often due to preventable smoking-related health conditions. Studies that identify barriers and facilitators to smoking cessation are crucial for policy makers and health care professionals. Aims This appraisal aims to identify and critically appraise qualitative studies which explore smoking experiences and barriers to smoking cessation among PWSMI. Method Articles were retrieved from electronic health related databases including Web of Science, Scopus, PubMed, Sage, Biomed, Medline, Embase, and electronic hand searches of bibliographies from key articles. Results Eleven papers were identified. Although the overall quality of studies were sufficient, most had limited information relating to trustworthiness and sociodemographic details. Cost savings and health benefits were frequently cited as facilitators to quitting, however may be of limited impact as smoking for existential purposes, social inclusion, and mental health management appear to be considered highly important among PWSMI. Conclusions Findings were restricted to predominantly individual barriers to smoking cessation which may be more resistant to change as service users rely on smoking to manage their mental health and smoking is embedded in the culture of mental health settings. Implications This critical appraisal identifies qualitative evidence regarding which factors facilitate or prevent individuals with severe mental illness from engaging with smoking cessation. Healthcare professionals and policy makers should address external barriers to quitting smoking as this may increase participation in intervention studies, inform policy and assist in the development of a feasible and acceptable smoking cessation intervention among PWSMI. Methodological considerations highlight that future research should include sociodemographic and contextual factors to improve utility and applicability of findings.

Summary Background Little research has been done into the effectiveness of mental health supported accommodation services. We did a national survey to investigate provision and costs of services and assess service user quality of life and outcomes across England. Methods We randomly sampled three types of services from 14 nationally representative regions—residential care, supported housing, and floating outreach—and recruited up to ten service users per service. Service quality and costs and service users' quality of life, autonomy, and satisfaction with care were assessed in a standardised manner with validated tools and compared by multilevel modelling. Findings 619 service users were recruited from 22 residential care, 35 supported housing, and 30 floating outreach services. Those in residential care and supported housing had more severe mental health problems than those in floating outreach. 348 (57%) were assessed as being at risk of severe self-neglect and 229 (37%) as being vulnerable to exploitation in the previous 2 years. Residential care was most expensive but provided for people with the greatest needs. The mean annual budget was £466 687 for residential care (range £276 000–777 920), compared with £365 452 for supported housing (£174 877–818 000), and £172 114 for floating outreach (£17 126–491 692). Quality of care was best in supported housing. People in supported housing and floating outreach were more socially included but experienced more crime than those in residential care. After adjustment for service quality and service user sociodemographic and clinical factors, quality of life was similar for service users in residential care and supported housing (mean difference −0·138, 95% CI −0·402 to 0·126, p=0·306) and lower for those in floating outreach than in residential care (−0·424, −0·734 to −0·114, p=0·007). However, autonomy was greater for those in supported housing than for those in residential care (0·145, 0·010 to 0·279, p=0.035). Satisfaction with care was similar across services. Interpretation Supported housing might be cost-effective, but the benefits need to be weighed against the risks associated with increased autonomy. Funding National Institute for Health Research.

In recent years, social exclusion has gained the attention of governments around the world. This paper reports on a qualitative study involving 27 young men aged 14-19 years experiencing particular forms of exclusion in the context of Northern Irish society. The study used a focus group methodology to elicit their views with the aim of exploring both emotional and psychological needs and the structural factors that may contribute to their experiences of social exclusion. The findings reveal a range of unmet social and psychological needs, the impact of sectarianism and segregation, and a paucity of support systems in place. The paper concludes by making recommendations about how policy-makers and practitioners could find more imaginative ways of engaging such vulnerable young men to reduce social exclusion. Language: en

A perennial theme in the literature of religion and mental health is the need for dialogue between psychiatry and faith-based organisations in the care of people with mental health problems. These worlds are often depicted as oppositional and antagonistic; at times the boundaries are so tightly drawn that it is hard to see where they might share values and concerns. This paper examines the interface areas of religion and mental health care in order to consider where consensus and from where collaboration might emerge. We suggest that while certainly there is a need for dialogue and mutual understanding, there is also a need for psychiatry and faith groups to explore the nature and boundaries of proposed relationships.

Changes in socio-economic position in people who migrate may have adverse associations with mental health. The main objective of this review was to assess the association of social mobility with common mental disorders in migrant and second-generation groups, to inform future research.Systematic review and meta-analysis of English-language studies assessing the association of social mobility in migrant or second-generation groups with common mental disorders. Approaches to operationalise 'social mobility' were reviewed.Twelve studies (n=18,548) met criteria for retrieval. Very few included second-generation groups, and most studies were cross-sectional in design. Approaches to operationalise 'social mobility' varied between studies. Downward intragenerational social mobility was associated with migration in the majority of studies. Random effects meta-analysis (n=5179) suggested that migrants to higher income countries who experienced downward mobility or underemployment were more likely to screen positive for common mental disorders, relative to migrants who were upwardly mobile or experienced no changes to socio-economic position. Conclusions on second-generation groups were limited by the lack of research highlighted for these groups. Downward intragenerational mobility associated with migration may be associated with vulnerability to common mental disorders in some migrant groups.Given the increasing scale of global migration, further research is needed to clarify how changes to socio-economic position associated with international migration may impact on the mental health of migrants, and in their children.

Patient non-attendance and failure to engage with health services may be costly to the individual in terms of the delays in obtaining appropriate treatment and the unnecessary suffering and discomfort this may entail. Non-attendance is also costly to health services because of administrative and clinical time lost and the opportunity costs of not treating other patients. Patients who have been referred to eating disorders clinics by general practitioners appear to have high rates of non-attendance or dropping out immediately after assessment. The reasons behind their failure to engage are poorly understood. After undertaking a comprehensive audit in a major eating disorder unit in London we undertook a qualitative study of non-attenders in order to obtain the reasons behind non-engagement. We found that while participants tend to open their explanations with practical difficulties (e.g., child-minding) or service- related factors, what commonly emerged from their narratives were profound social-psychological problems and the ambivalence of confronting or losing a relationship with food that was both comforting and debilitating. Some participants described a world of imprisonment which precluded the likelihood of firm engagement with services. We suggest that such people may require better identification and outreach provision.

BackgroundPreliminary studies in the UK, all using screening instruments of unknown cultural validity, indicate that there may be an increased prevalence of dementia in African–Caribbean people, possibly related to vascular risk factors and potentially amenable to preventative measures.AimsTo determine the prevalence of dementia in older people of African–Caribbean country of birth compared with their White UK-born counterparts.MethodA total of 218 people of African–Caribbean country of birth and 218 White UK-born people aged ⩾60 years were recruited from five general practices in North London. Those who screened positive for cognitive impairment using a culturally valid instrument were offered a standardised diagnostic interview. Two independent assessors diagnosed dementia according to standard operationalised criteria.ResultsAfrican–Caribbean participants were 2 years younger, and those with dementia nearly 8 years younger than their White counterparts. The prevalence of dementia was significantly higher in the African–Caribbean (9.6%) than the White group (6.9%) after adjustment for the confounders age and socioeconomic status (odds ratio (OR) = 3.1, 95%CI 1.3–7.3, P = 0.012).ConclusionsThere is an increased prevalence of dementia in older people of African–Caribbean country of birth in the UK and at younger ages than in the indigenous White population. These findings have implications for service provision and preventive interventions. Further research is needed to explore the role of vascular risk factors and social adversity in the excess of dementia in this population.

This article uses a qualitative approach to elicit the views of 31 professionals who provide services to vulnerable young men. The findings reveal six key themes following focus group interviews: (i) the importance of masculinity in explaining problematic behaviour; (ii) the misuse of alcohol and drugs; (iii) alienation and social isolation; (iv) concerns about suicide and self-harm; (v) the quality of existing services; and (vi) recommendations for changes to services. Service providers generally acknowledged the social context in explaining these behaviours and argued for enhanced services and a more developed skills base in working with vulnerable young men.

The suicide rate in Northern Ireland, particularly among young men has grown rapidly in recent years. A relatively religious society, compared to other UK European regions, a needs assessment of clergy's pastoral response to mental illness and suicide was undertaken as part of the suicide prevention strategy. We carried out in-depth interviews with 37 clergy from a range of Christian denominations. While a compassionate response to suicide by clergy was commonly advocated, made permissible by an attribution to mental illness, there remain some misgivings about a “softer” theological stance towards suicide. This article describes clergy explanatory models of suicide and discusses the issue of cognitive dissonance on this subject.

This article provides an overview of the literature on the impact of ‘the Troubles’ on mental health in Northern Ireland. It identifies three main phases of professional and policy response from concerns about the effects of the violence in the early 1970s, through many years of collective denial and neglect, until acknowledgment, following the Good Friday Agreement in 1998 (Northern Ireland Office, 1998), of high levels of trauma and unmet need. The issues of inequality and stigma are also considered and it is argued that peace is necessary but insufficient for promoting mental health. The development of mental health services in Northern Ireland and the relatively recent focus on promoting mental health are also outlined and examined. It is suggested that attempts to address the needs arising as a result of ‘the Troubles’ and more general mental health promotion strategies have, to some extent, developed in parallel and that it may be important to integrate these efforts. The relative under‐development of mental health services, the comprehensive Bamford Review (2005; 2006) and the positive approach of the Public Health Agency mean that, even in the current economic climate, there are great opportunities for progress. Routine screening, in primary care and mental health services for trauma, including Troubles‐related trauma, is recommended to identify and address these issues on an individual level. It is also argued, however, that more substantial political change is needed to effectively address societal division, inequality and stigma to the benefit of all.

Clergy in the UK continue to provide health and social care services. However, collaboration between mental health services and clergy may be problematic, particularly in the resolution of conflicting beliefs and therapeutic modalities. For example, belief in demonic possession and other supernatural causes of mental illness, which are contentious among secular medical practitioners, remain prevalent in many ethnoreligious communities. Thus, interpretations of illness by clergy within health systems may be crucial to appropriate intervention for people with mental illness. However, clergy conceptualizations of suffering also reveal something about the secularization within religious institutions through the despiritualization of particular phenomena. This paper on Christian clergy beliefs and attitudes to supernatural explanations, describes how the negotiation of such beliefs are complex and often equivocal among mainstream clergy but integral to the Pentecostal churches and evangelical clergy in the mainstream, institutional churches. These beliefs and their implications for collaboration with psychiatry are discussed in the context of a rapidly changing religious and cultural landscape.

Differences in outcome between African-Caribbean and white British patients with psychosis may be due to perceived racism and a difficulty in trusting services seen as discriminatory.In 100 participants, racism was measured at baseline using the Perceived Racism Scale; with adherence, using the Drug Attitudes Inventory and Kemp Scale, and hospital admission data determined after 12 months.We found associations between total perceived racism for the previous year (b = -0.0074, P = 0.013), lifetime racism (b = -0.0068, P = 0.038), and everyday racism for the previous year (b = -0.051, P = 0.0046), with subsequent medication adherence. Shame felt about health system racism was associated with increased adherence (b = 0.20, P = 0.015), and powerlessness about it was associated with fewer subsequent hospital bed days (b = -14.49, P = 0.025). Finally, health system racism was associated with both the number of subsequent hospital bed days (b = 5.54, P = 0.010), and admission length (b = 4.92, P = 0.021). In addition, stratified analyses showed that both baseline adherence and 6-month estimated adherence appeared to mediate these effects.In this cohort of African-Caribbean patients with psychosis, perceived racism is a determinant of adherence over 12 months. We propose a model whereby perceived racism contributes to an individual rejecting mental health services (manifested by the mediating effect of poor adherence) which leads to a poorer outcome, evidenced by a longer hospital stay. Secondly, powerlessness about perceived health-service racism may represent a sense of resignation about the "system", leading paradoxically to greater adherence and better outcome.

SummaryIn this article we suggest that controversy over interventions such as prayer in psychiatric practice distracts attention from a serious consideration of the role of spirituality in our society. There is abundant evidence that spiritual belief, experience and practice gives meaning to many people and thus whatever they think of its truth value, psychiatrists cannot ignore it.

There is a growing expectation that schoolteachers should not only act as educators by delivering the national curriculum, but also be more involved as tier one mental health professionals. In this role they are expected to assume some responsibility in the early identification of children's mental health problems and to refer these children for appropriate support as required [NHS Health Advisory Service. (1995). Together we stand: The commissioning, role and management of child and adolescent mental health services. London, UK: HMSO]. In this paper, we examine teachers’ experiences in light of these expectations and in the context of greater inclusion. We undertook in-depth interviews, to explore teachers’ views on competency and training in mental health management. Our findings indicate a widespread perception that teachers feel inadequately prepared to manage pupils with mental health needs. The findings are discussed with reference to the changing role of the teacher, current education policy and teacher training.

This paper describes an ethnographic perspective on the role of a Muslim shrine in Pakistan. Most shrines in Muslim countries represent the Sufi tradition in Islam where followers seek healing and fulfilment of their wishes using Sufi saints as intermediaries. In Pakistan, the shrine of Hazrat Abdullah Shah Ashabi provides a significant religious, social, physical, and psychological resource where people engage in religious rituals, community living and healing rituals to address physical, emotional, and social ailments. In addition to the explanatory models of misfortune described by the informants, gender, poverty, availability of formal health services, and social support seem to play a significant role in emphasizing the position of the Sufi shrine in a Muslim setting.

Summary Objectives To establish the feasibility of conducting a randomised controlled trial to evaluate the efficacy of acupuncture in the treatment of mild-to-moderate depression. Control group intervention, blinding of treatment, outcome measures and the acceptability of such a trial amongst participants were key factors to be addressed. The findings from this study will be used to determine the design of a phase III randomised controlled trial. Design Nineteen participants were recruited through general practices in London, UK. Participants were randomly assigned on a 2:1 basis to either 12 sessions of verum acupuncture or 12 sessions of sham acupuncture (control). Sham acupuncture involved actual needling but at sites considered to be unrelated to depression. Main outcome measures The Beck's Depression Inventory (BDI) and the RAND 36 Item Health Survey 1.0 (RAND) were completed at baseline and at the end of treatment or at treatment dropout. All participants also attended a brief qualitative interview at the end of the study. Results Treatment dropout was low and there were high levels of patient enthusiasm for a study of acupuncture. Referrals from General Practitioners (GPs) were lower than expected. The sham control method successfully maintained participant blinding to treatment and enabled the specific (or active) component of an acupuncture intervention to be isolated and its efficacy assessed. The outcome measures were sensitive enough to record changes in depressive symptoms and quality of life and are appropriate for use in a larger trial. Conclusions This feasibility study has provided important information that can be used to guide the design and methodology of a full-randomised controlled trial.

In this exploratory qualitative study we explored issues related to cultural sensitivity among 10 British therapists working in multicultural settings. Our analysis, which combined content and statistical procedures, suggests that knowledge of the client’s core ethnic identity and the degree of adherence to religious or traditional values are the most prominent issues that practitioners take into consideration. Understanding the client’s kinship and migration history were also highlighted as important for a positive therapeutic outcome. Furthermore, therapists strongly indicated knowledge and thus cultural sensitivity is predominantly gained through direct contact with clients rather than gained through additional training and external advice. We used Multidimensional Scalogram Analysis (MSA), to obtain two dominant perspectives that we suggest guides multicultural counselling. One approach takes into account specific cultural information. A second acknowledges the significance of cultural and racial issues but gives preference to individual experiences of racism. Therapists’ socio-demographic variables or preferred theoretical perspective didn’t appear to affect the different models outlined. Implications of our findings are discussed.

The transfer of psychiatric care from the institution to the community has presented community structures including faith-based organisations (FBOs) with an additional burden of care. In recent years there has been an increasing policy interest among government departments, public and non-statutory agencies for the inclusion of FBOs as partners in health and welfare services. However, despite their long historical involvement in healing and healthcare, clergy are seldom viewed by mental health professionals as partners in healing and restitution but with suspicion [Koenig, 1988. Handbook of Religion and Mental Health San Diego: Academic Press; Larson, Hohmann, & Kessler, 1988. The couch and the cloth: The need for linkage. Hospital and Community Psychiatry, 39, 1064-1069]. This may be compounded by ignorance about mental health care provision within FBOs in the UK and the preparedness, confidence and willingness to undertake such care. This paper is based on a study which examined clergy contact with people with mental illness. Thirty-two interviews were conducted with male clergy (Christian ministers, rabbis, and imams) most of whom were London-based. We examine barriers and dilemmas for clergy in caring for people with mental illness. We found that they play an important but often confined role the scale and impact of which is not recognised by their central organisation and training bodies. Low confidence about managing psychiatric problems, underscored by anxiety, fear and stereotyped attitudes to mental illness restrain their willingness to formalise their function. We argue that any proposed extension of clergy involvement in mental health will require further research and thorough deliberation by mental health services and religious organisations.

Khat has been used as a stimulant plant in many parts of Africa and the Arabian Peninsula for centuries. Its current use among particular migrant communities in Europe and elsewhere has caused alarm among policy makers and health care professionals. In the United Kingdom, the debate over the psychiatric and social implications of khat use has led to a demand for stricter legal control of this stimulant plant. This paper (a) provides a historical overview of khat use, and (b) reviews the evidence for the existence of a causal link between khat use and mental illness. To do so, we undertook a detailed search of social and medical science databases for case reports, qualitative and quantitative articles on khat use and mental illness from 1945 to 2006. The validity and reliability of the studies that met our inclusion criteria were examined. Lastly, although highlighting health concerns about khat use we suggest that the debate about this popular drug in migrant populations carries elements of a 'moral panic'. There is a need for improved research on khat use and its possible association with psychiatric disorders.

The provision of counselling services for refugee and asylum-seeking patients is relatively new in the UK and their complex needs may present considerable challenges within primary care, where access to specialist support resources is often limited. As far as we know, no previous research has attempted to look at the experiences of the counsellors who do this work. We undertook in-depth interviews with 13 counsellors who provide counselling to refugees in primary care in north London. The findings of this study suggest that counsellors who work in a primary care setting find themselves conflicted, troubled and out of their depth by the experiences, narratives and distress presented by refugee and asylum-seeking patients. They also report an erosion of usual counselling boundaries. Thus, the problems presented by refugees seem to demand approaches which go beyond standard counselling practice and which create ambivalence and uncertainty. These counsellors express feelings of isolation and impotenc...

This paper provides an overview of the evidence on the perspective of health care professionals (HCPs) in relation to advance care planning (ACP) for people with dementia, residing in long-term care settings. A narrative approach was adopted to provide a comprehensive synthesis of previously published literature in the area. A systematic literature search identified 14 papers for inclusion. Following review of the studies four themes were identified for discussion; Early integration and planning for palliative care in dementia; HCPs ethical and moral concerns regarding ACP; Communication challenges when interacting with the person with dementia and their families and HCPs need for education and training. Despite evidence, that HCPs recognise the potential benefits of ACP, they struggle with its implementation in this setting. Greater understanding of dementia and the concept of ACP is required to improve consistency in practice. Synthesising the existing evidence will allow for further understanding of the key issues, potentially resulting in improved implementation in practice.

Background No standardised tools for assessing the quality of specialist mental health supported accommodation services exist. To address this, we adapted the Quality Indicator for Rehabilitative care-QuIRC-that was originally developed to assess the quality of longer term inpatient and community based mental health facilities. The QuIRC, which is completed by the service manager and gives ratings of seven domains of care, has good psychometric properties. Methods Focus groups with staff of the three main types of supported accommodation in the UK (residential care, supported housing and floating outreach services) were carried out to identify potential amendments to the QuIRC. Additional advice was gained from consultation with three expert panels, two of which comprised service users with lived experience of mental health and supported accommodation services. The amended QuIRC (QuIRC-SA) was piloted with a manager of each of the three service types. Item response variance, inter-rater reliability and internal consistency were assessed in a random sample of 52 services. Factorial structure and discriminant validity were assessed in a larger random sample of 87 services. Results The QuIRC-SA comprised 143 items of which only 18 items showed a narrow range of response and five items had poor inter-rater reliability. The tool showed good discriminant validity, with supported housing services generally scoring higher than the other two types of supported accommodation on most domains. Exploratory factor analysis showed that the QuIRC-SA items loaded onto the domains to which they had been allocated. Conclusions The QuIRC-SA is the first standardised tool for quality assessment of specialist mental health supported accommodation services. Its psychometric properties mean that it has potential for use in research as well as audit and quality improvement programmes. A web based application is being developed to make it more accessible which will produce a printable report for the service manager about the performance of their service, comparison data for similar services and suggestions on how to improve service quality. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0799-4) contains supplementary material, which is available to authorized users.

Backgound: Limited data suggest that crime may have a devastating impact on older people. Although identification and treatment may be beneficial, no well-designed studies have investigated the prevalence of mental disorder and the potential benefits of individual manualized CBT in older victims of crime. Aims: To identify mental health problems in older victims of common crime, provide preliminary data on its prevalence, and conduct a feasibility randomized controlled trial (RCT) using mixed methods. Method: Older victims, identified through police teams, were screened for symptoms of anxiety, depression or post-traumatic stress disorder (PTSD) one (n = 581) and 3 months (n = 486) after experiencing a crime. Screen positive participants were offered diagnostic interviews. Of these, 26 participants with DSM-IV diagnoses agreed to be randomized to Treatment As Usual (TAU) or TAU plus our manualized CBT informed Victim Improvement Package (VIP). The latter provided feedback on the VIP. Results: Recruitment, assessment and intervention are feasible and acceptable. At 3 months 120/486 screened as cases, 33 had DSM-IV criteria for a psychiatric disorder; 26 agreed to be randomized to a pilot trial. There were trends in favour of the VIP in all measures except PTSD at 6 months post crime. Conclusions: This feasibility RCT is the first step towards improving the lives of older victims of common crime. Without intervention, distress at 3 and 6 months after a crime remains high. However, the well-received VIP appeared promising for depressive and anxiety symptoms, but possibly not posttraumatic stress disorder.

Mounting evidence of a crisis in mental health care for young people has underlined the need for early and better recognition of mental health difficulties in children. Recent policy suggests that schools and teachers must play a pivotal role in smoother pathways to care. This will necessitate enhanced working relationships between schools and child and adolescent mental health services (CAMHS). However, there is little understanding as to how teachers and mental health professionals currently relate to one another or what difficulties undermine ‘joined up’ care. In this study we examine current systems of collaboration between schools and child and adolescent mental health services, paying particular attention to relationships between schoolteachers and mental health professionals. Data was collected using semi‐structured, in‐depth interviews. Our findings indicate deep‐seated barriers to good collaboration. Moreover, teachers experience significant frustration through feeling excluded from the mental health care management of children despite being affected professionally by such decisions taken, the delays to intervention and poor communication between agencies. Interprofessional trust and mutual suspicion emerged from these interviews as an over‐arching factor. The implications arising from expectations for greater inter‐agency collaboration are discussed.

In the United Kingdom, the issue of health and social care of young people is now a major concern for the government. Thus, a recent government green paper has insisted on the provision of early and appropriate interventions for young peoples' mental health difficulties and that their views must be incorporated into the design of mental health services. More recently, the NHS Health Advisory Service has recommended that schools and teachers should assume some responsibility in the identification of pupils who may have mental health difficulties. Unfortunately, there is scant information in the United Kingdom on young peoples' pathways into services. We know very little about their help-seeking strategies and service use, barriers or facilitators to care, satisfaction with services and service preferences. In addition, we have limited knowledge of how young people conceptualize mental health or how they perceive mental health professionals. In brief, the needs and help-seeking behaviours of young ...

There is a growing recognition of the importance of pre‐literacy skills among pre‐school children. Evidence that children from relatively deprived backgrounds face poorer outcomes in speech and language development and educational achievement has led to an assertive attempt to lessen social inequalities at the earliest opportunity. The UK government‐funded Sure Start initiative aims to provide services to promote play and learning opportunities for such children under the age of four. This paper describes the background and method of setting up an Early Listening programme in a deprived, multicultural and multilingual area of North London. We also present findings on the effect of the programme on children's phonological awareness. The results indicated improvement in rhyme awareness following direct input, with more tentative signs of positive trends in phonemic awareness and visual memory. We suggest that this programme may have considerable value in a wider local educational context. The information ga...

The changeover to single sex accommodation in psychiatric hospitals was intended to strengthen patients' dignity, safety and privacy (DoH 2000). Previous research on patients' attitudes to single sex accommodation suggests that female patients in particular are in favour, although the views of staff are less well known. Our aim was to examine both patient and staff perspectives on single-sex accommodation. We surveyed patients in acute psychiatric wards using a patient questionnaire that covered satisfaction of care and preference for single or mixed sex accommodation. In addition we undertook brief in-depth interviews using a semi-structured questionnaire with patients and staff in order to gain a better understanding of this issue. The results revealed that safety is a major concern in determining patient satisfaction with services. Female patients were much more likely to prefer segregated accommodation than men (χ2 = 26.56, df = two, p < 0.0000). Patients suggest that diagnosis, severity of illness, and age are equally important in determining hospital accommodation and a safe, therapeutic environment. Male staff are concerned with potential allegations of sexual harassment, while women staff view single-sex accommodation as a threat to creating a more natural environment for patients. We conclude that while the majority of women patients favour single sex accommodation. The results of this study indicate that the views of patient and staff are more complex. Patient concerns of safety on psychiatric wards may not be wholly resolved by the introduction of single-sex accommodation. Clear policy guidelines and training must also be provided for staff members.

Little is known about how patients with long-term eating disorders manage their clinical problems. We carried out a preliminary qualitative study (using Thematic Analysis) of patients with severe and enduring anorexia nervosa (SEED-AN) in which we undertook recorded interviews in eight participants whose conditions had lasted 20-40 years. We found 15 principle features in physical, psychological, social, family, occupational and treatment realms. Psychological and social realms were most affected. Severe physical problems were reported. They described feelings of unworthiness, frugality regarding money and obsessive time-keeping. Persisting with negligible social networks, participants described depression and hopelessness, while somehow achieving a sense of pride at their endurance and survival in spite of the eating disorder. They emphasized the importance of professional help in managing their care. The severe and enduring description, often reserved for people with psychotic illness, is appropriately applied to SEED-AN, which has major impacts in all realms.