Search

BackgroundThere is some evidence of inequitable psychosis care provision by ethnicity. We investigated variations in the receipt of CBTp and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all.MethodsWe included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression to examine odds ratios of receiving an intervention (CBTp, family intervention, or either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload and mental health inequalities strategies).FindingsCompared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had lower adjusted odds of receiving CBTp (aOR 0·39, 95%CI 0·32-0·47 to 0·80, 0·64-1·00). People of Black African (0·61, 0·53-0·69), Black Caribbean (0·67, 0·56-0·81), non-African/Caribbean Black (0·63, 0·51-0·79), non-British/Irish White (0·73, 0·64-0·84), and of “any other” (0·66, 0·54-0·81) ethnicity also experienced lower adjusted odds of receiving family intervention.InterpretationPervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority, allowing co-produced development and testing of approaches to address them.FundingIndependent research commissioned and funded by the National Institute for Health Research Policy Research Programme.

BackgroundIn England, a range of mental health crisis care models and approaches to organising crisis care systems have been implemented, but characteristics associated with their effectiveness are poorly understood.AimsTo i) develop a typology of catchment area mental health crisis care systems and ii) investigate how crisis care service models and system characteristics relate to psychiatric hospital admissions and detentions.MethodsData about crisis systems were obtained from a 2019 English national survey. Latent class analyses were conducted to identify discernible typologies, and mixed effects negative binomial regression models were fitted to explore associations between crisis care models and admissions and detention rates, obtained from nationally-reported data.ResultsNo clear typology of catchment area crisis care systems emerged. Regression models suggested that provision of a crisis telephone service within the local crisis system was associated to a 11.6% lower admissions rate and a 15.3% lower detention rate. Provision of a crisis café was associated with a 7.8% lower rate of admissions. The provision of a crisis assessment team separate from the crisis resolution and home treatment service was associated with a 12.8% higher rate of admissions.ConclusionsThe configuration of crisis care systems varies considerably in England, but we could notderive a typology which convincingly categorised crisis care systems. Our results suggest that a crisis phone line and a crisis café may be associated with lower rates of admission, but crisis assessment teams, separate from home treatment teams, may not be associate to reductions in hospital admission and detentions.

PurposeWe sought to understand how the experiences of people in the UK with pre-existing mental health conditions had developed during the course of the COVID-19 pandemic.MethodsIn September-October 2020 we interviewed adults with mental health conditions pre-dating the pandemic, whom we had previously interviewed three months earlier. Participants had been recruited through online advertising and voluntary sector community organisations. Interviews were conducted by telephone or video-conference by researchers with lived experience of mental health difficulties, and explored changes over time in people’s experience of the pandemic.ResultsWe interviewed 44 people, achieving diversity of demographic characteristics and a range of mental health conditions and service use among our sample. Three overarching themes were derived from interviews. The first theme “Spectrum of adaptation”: to difficulties in access to, or the quality of, statutory mental health services, through developing new personal coping strategies or identifying alternative sources of support. The second theme is “Accumulating pressures”: from pandemic-related anxieties and sustained disruption to social contact and support, and to mental health treatment. The third theme “Feeling overlooked”: A sense of people with pre-existing mental health conditions being overlooked during the pandemic by policy-makers at all levels. The latter was compounded for people from ethnic minority communities or with physical health problems.ConclusionOur study highlights the need to support marginalised groups who are at risk of increased inequalities, and to maintain crucial mental and physical healthcare and social care for people with existing mental health conditions, notwithstanding challenges of the pandemic.

Background Inpatient psychiatric care is unpopular and expensive, and development and evaluation of alternatives is a long-standing policy and research priority around the world. In England, the three main models documented over the past fifty years (teams offering crisis assessment and treatment at home; acute day units; and residential crisis services in the community) have recently been augmented by several new service models. These are intended to enhance choice and flexibility within catchment area acute care systems, but remain largely undocumented in the research literature. We therefore aimed to describe the types and distribution of crisis care models across England through a national survey. Methods We carried out comprehensive mapping of crisis resolution teams (CRTs) using previous surveys, websites and multiple official data sources. Managers of CRTs were invited to participate as key informants who were familiar with the provision and organisation of crisis care services within their catchment area. The survey could be completed online or via telephone interview with a researcher, and elicited details about types of crisis care delivered in the local catchment area. Results We mapped a total of 200 adult CRTs and completed the survey with 184 (92%). Of the 200 mapped adult CRTs, there was a local (i.e., within the adult CRT catchment area) children and young persons CRT for 84 (42%), and an older adults CRT for 73 (37%). While all but one health region in England provided CRTs for working age adults, there was high variability regarding provision of all other community crisis service models and system configurations. Crisis cafes, street triage teams and separate crisis assessment services have all proliferated since a similar survey in 2016, while provision of acute day units has reduced. Conclusions The composition of catchment area crisis systems varies greatly across England and popularity of models seems unrelated to strength of evidence. A group of emerging crisis care models with varying functions within service systems are increasingly prevalent: they have potential to offer greater choice and flexibility in managing crises, but an evidence base regarding impact on service user experiences and outcomes is yet to be established.

OBJECTIVE: To investigate whether continuity of care in family practice reduces unplanned hospital use for people with serious mental illness (SMI).DATA SOURCES: Linked administrative data on family practice and hospital utilization by people with SMI in England, 2007-2014.STUDY DESIGN: This observational cohort study used discrete-time survival analysis to investigate the relationship between continuity of care in family practice and unplanned hospital use: emergency department (ED) presentations, and unplanned admissions for SMI and ambulatory care-sensitive conditions (ACSC). The analysis distinguishes between relational continuity and management/ informational continuity (as captured by care plans) and accounts for unobserved confounding by examining deviation from long-term averages.DATA COLLECTION/EXTRACTION METHODS: Individual-level family practice administrative data linked to hospital administrative data.PRINCIPAL FINDINGS: Higher relational continuity was associated with 8-11 percent lower risk of ED presentation and 23-27 percent lower risk of ACSC admissions. Care plans were associated with 29 percent lower risk of ED presentation, 39 percent lower risk of SMI admissions, and 32 percent lower risk of ACSC admissions.CONCLUSIONS: Family practice continuity of care can reduce unplanned hospital use for physical and mental health of people with SMI.

Objective:Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality.Methods:Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality.Results:Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98–1.32), ED visit (HR=0.95; 95% CI=0.80–1.14), or death (HR=1.02; 95% CI=0.76–1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality.Conclusions:The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected.

Purpose The purpose of this paper is to understand how women with a diagnosis of schizophrenia or bipolar disorder approach medication decision making in pregnancy. Design/methodology/approach The study was co-produced by university academics and charity-based researchers. Semi-structured interviews were conducted by three peer researchers who have used anti-psychotic medication and were of child bearing age. Participants were women with children under five, who had taken anti-psychotic medication in the 12 months before pregnancy. In total, 12 women were recruited through social media and snowball techniques. Data were analyzed following a three-stage process. Findings The accounts highlighted decisional uncertainty, with medication decisions situated among multiple sources of influence from self and others. Women retained strong feelings of personal ownership for their decisions, whilst also seeking out clinical opinion and accepting they had constrained choices. Two styles of decision making emerged: shared and independent. Shared decision making involved open discussion, active permission seeking, negotiation and coercion. Independent women-led decision making was not always congruent with medical opinion, increasing pressure on women and impacting pregnancy experiences. A common sense self-regulation model explaining management of health threats resonated with women’s accounts. Practical implications Women should be helped to manage decisional conflict and the emotional impact of decision making including long term feelings of guilt. Women experienced interactions with clinicians as lacking opportunities for enhanced support except in specialist perinatal services. This is an area that should be considered in staff training, supervision, appraisal and organization review. Originality/value This paper uses data collected in a co-produced research study including peer researchers.

Background: People with severe mental illness die 15-20 years earlier than the general population. This excess mortality is explained largely by preventable physical health conditions. Evaluating the effectiveness of interventions that target risk behaviours in people with SMI is a global health priority. Interventions focussing on single behaviours may be ineffective in changing health outcomes. No systematic review has compared the effectiveness of targeting multiple or single risk behaviours in this population. Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), Embase, MEDLINE, PsycINFO and Science Citation Index in March 2020 and Applied Social Science Index and Abstracts (ASSIA) in September 2020. We included randomised controlled trials of single or multiple health risk behaviour interventions in people with SMI. The study is registered on PROSPERO (CRD42018104724). We conducted network meta-analyses to compare effectiveness of interventions targeting multiple and single risk behaviours. Findings: We included 67 RCTs. Just over half of studies had high overall risk of bias. Trials focusing on smoking alone led to greater smoking abstinence than targeting smoking and other behaviours. However, heterogeneity means we cannot rule out other interpretations explanations. For weight loss (e.g. any risk behaviour intervention: -2.10 kg, 95% CrI -3.14, -1.06) and BMI (e.g. any risk behaviour intervention: -0.49, 95% CrI -0.97, -0.01) all risk behaviour interventions had positive but modest benefits compared with treatment as usual. There were potential synergies for targeting multiple health behaviours for reduction in systolic blood pressure. We found no evidence of a deterioration in mental health for people with SMI engaging in these interventions. Interpretation: Multiple and single risk behaviour interventions were associated with positive but modest benefits. Targeting smoking alone appeared to be more effective, but few studies assessed behavioural outcomes. Interventions were not associated with deterioration in mental health. Funding: National Institute for Health Research Declaration of Interest: We declare no competing interests.

BackgroundWeaknesses in the provision of mental health crisis support are evident and improvements that include voluntary sector provision are promoted. There is a lack of evidence regarding the contribution of the voluntary sector and how this might be used to the best effect in mental health crisis care.AimTo investigate the contribution of voluntary sector organisations to mental health crisis care in England.DesignMultimethod sequential design with a comparative case study.SettingEngland, with four case studies in North England, East England, the Midlands and London.MethodThe method included a scoping literature review, a national survey of 1612 voluntary sector organisations, interviews with 27 national stakeholders and detailed mapping of the voluntary sector organisation provision in two regions (the north and south of England) to develop a taxonomy of voluntary sector organisations and to select four case studies. The case studies examined voluntary sector organisation crisis care provision as a system through interviews with local stakeholders (n = 73), eight focus groups with service users and carers and, at an individual level, narrative interviews with service users (n = 47) and carers (n = 12) to understand their crisis experience and service journey. There was extensive patient and public involvement in the study, including service users as co-researchers, to ensure validity. This affected the conduct of the study and the interpretation of the findings. The quality and the impact of the involvement was evaluated and commended.Main findingsA mental health crisis is considered a biographical disruption. Voluntary sector organisations can make an important contribution, characterised by a socially oriented and relational approach. Five types of relevant voluntary sector organisations were identified: (1) crisis-specific, (2) general mental health, (3) population-focused, (4) life-event-focused and (5) general social and community voluntary sector organisations. These voluntary sector organisations provide a range of support and have specific expertise. The availability and access to voluntary sector organisations varies and inequalities were evident for rural communities; black, Asian and minority ethnic communities; people who use substances; and people who identified as having a personality disorder. There was little evidence of well-developed crisis systems, with an underdeveloped approach to prevention and a lack of ongoing support.LimitationsThe survey response was low, reflecting the nature of voluntary sector organisations and demands on their time. This was a descriptive study, so evaluating outcomes from voluntary sector organisation support was beyond the scope of the study.ConclusionsThe current policy discourse frames a mental health crisis as an urgent event. Viewing a mental health crisis as a biographical disruption would better enable a wide range of contributory factors to be considered and addressed. Voluntary sector organisations have a distinctive and important role to play. The breadth of this contribution needs to be acknowledged and its role as an accessible alternative to inpatient provision prioritised.Future workA whole-system approach to mental health crisis provision is needed. The NHS, local authorities and the voluntary sector should establish how to effectively collaborate to meet the local population’s needs and to ensure the sustainability of the voluntary sector. Service users and carers from all communities need to be central to this.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 29. See the NIHR Journals Library website for further project information.

BackgroundPeople with serious mental illness (SMI) have sexual health needs but there is little evidence to inform effective interventions to address them. In fact, there are few studies that have addressed this topic for people with SMI outside USA and Brazil. Therefore, the aim of the study was to establish the acceptability and feasibility of a trial of a sexual health promotion intervention for people with SMI in the UK.MethodThe RESPECT study was a two-armed randomised controlled, open feasibility study comparing Sexual health promotion intervention (3 individual sessions of 1 hour) (I) or usual care (UC) for adults aged 18 or over, with SMI, within community mental health services in four UK cities. The main outcome of interest was the percentage who consented to participate, and retained in each arm of the trial, retention for the intervention, and completeness of data collection. A nested qualitative study obtained the views of participants regarding the acceptability of the study using individual telephone interviews conducted by lived experience researchers. ResultsOf a target sample of 100, a total of 72 people were enrolled in the trial over 12 months. Recruitment in the initial months was low and so an extension was granted. However this extension meant that the later recruited participants would only be followed up to the 3 month point. There was good retention in the intervention and the study as a whole; 77.8% of those allocated to intervention (n=28) received it. At three months, 81.9% (30 I; 29 UC) and at 6 months, 76.3% (13 I and 16 UC) completed the follow-up interviews. No adverse events were reported. There was good completeness of the data. The sexual health outcomes for the intervention group changed in favour of the intervention. Based on analysis of the qualitative interviews, the methods of recruitment, the quality of the participant information, the data collection, and the intervention were deemed to be acceptable to the participants (n=22). ConclusionsThe target of 100 participants was not achieved within the study’s timescale. However, effective strategies were identified that improved recruitment in the final few months. Retention rates and completeness of data in both groups indicate that it is acceptable and feasible to undertake a study promoting sexual health for people with SMI. A fully powered RCT is required to establish effectiveness of the intervention in adoption of safer sex.

Background People with serious mental illness have sexual health needs, but there is limited evidence regarding effective interventions to promote their sexual health. Objectives To develop a sexual health promotion intervention for people with serious mental illness, and to conduct a feasibility trial in order to establish the acceptability and parameters for a fully powered trial. Design A two-armed randomised controlled, open feasibility study comparing usual care alone with usual care plus the adjunctive intervention. Setting Five community mental health providers in Leeds, Barnsley, Brighton and London. Participants Adults aged ≥ 18 years with serious mental illness and receiving care from community mental health teams. Interventions A remote, web-based computer randomisation system allocated participants to usual care plus the RESPECT (Randomised Evaluation of Sexual health Promotion Effectiveness informing Care and Treatment) intervention (three sessions of 1 hour) (intervention arm) or usual care only (control arm). The intervention was an interactive manualised package of exercises, quizzes and discussion topics focusing on knowledge, motivation and behavioural intentions to adopt safer sexual behaviours. Main outcome measures Feasibility parameters including establishing the percentage of people who were eligible, consented and were retained in each arm of the trial, retention for the intervention, as well as the completeness of the data collection. Data were collected on knowledge, motivation to adopt safer sexual behaviour, sexual behaviour, sexual stigma, sexual health service use and quality of life. Data were collected at baseline and then at 3 months and 6 months post randomisation. Results Of a target of 100 participants, 72 people participated in the trial over 12 months. Of the 36 participants randomised to the intervention arm, 27 received some of the intervention (75.0%). At 3 months, 59 of the 72 participants completed follow-up questionnaires (81.9%) (30 participants from the intervention arm and 29 participants from the control arm). Only the first 38 participants were followed up at 6 months. However, data were collected on 29 out of 38 participants (76.3% retention): 13 in the intervention arm and 16 in the control arm. No adverse events were reported. Participant feedback confirmed that both the design and the intervention were acceptable. The economic analysis indicated high completion rates and completeness of data among participants who continued the trial. Conclusions Despite the limitations, the findings suggest that it is both acceptable and feasible to undertake a sexual health promotion study for people with serious mental illness. Future work A fully powered randomised controlled trial would be required to establish the clinical effectiveness of the intervention. Trial registration Current Controlled Trials ISRCTN15747739. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 65. See the NIHR Journals Library website for further project information.

ObjectiveTo investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI).Design, setting, participantsRetrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database.Outcomes and analysisCox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC).ResultsRisk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews.ConclusionsCare plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

BackgroundSerious mental illness (SMI) — which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses — has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care.AimThe objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care.Design and settingA systematic literature review, combined with a search of quality indicator databases and guidelines.MethodThe authors assessed whether indicators could be measured from routine data and the quality of the evidence.ResultsOut of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence.ConclusionWith appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.

BackgroundCrisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery.ObjectivesTo evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway.Data sourcesElectronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies.Study selectionWhen guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority.Study appraisal and synthesis methodsSystematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis.Results and limitationsOne review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well.Conclusions and implicationsMost evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams.Study registrationThis study is registered as PROSPERO CRD42014013279.FundingThe National Institute for Health Research HTA programme.