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Background While the link between deprivation and health is established, little is known about the association of persistent deprivation or deprivation trajectories over time with adverse health outcomes. Aim To examine latent class trajectories of area level-deprivation from 2010-2016 and their association with social distress indicators from 2017-2021. Method Analysis was based on linked administrative data (N=1,569,110) from NI GP Registrations Index, emergency department records (2017-21), enhanced prescribing data (2017-21) and biennial area-level deprivation (2010-2016). Latent class growth analysis (LCGA) identified deprivation trajectories between 2010 and 2016; and regression-based models, adjusted for age, sex and urbanicity, examined their association with indicators of individual level distress: occurrence of death, any accident and emergency (A&E) visit, and any psychotropic medication between 2017 and 2021. Results Based on comparison of models and fit statistics, a non-linear LGCA model identified six trajectories: consistently deprived (21.2%); slight improvement (7.1%); substantial improvement (1.2%); consistently average deprivation (31.7%); slight worsening (18.5%); and consistently non-deprived (20.4%). Consistently living in a deprived area was associated with higher likelihood of death, A&E visits and receipt of hypnotics, anxiolytics, and anti-depressants. Compared to consistent deprivation, slight improvement was associated with lower likelihood of death (OR=0.94, CI: 0.91-0.97) and all psychotropic medication in the follow-up period. Implications Findings indicate that even a slight improvement in deprivation status can have a positive influence on health outcomes. Further population-wide analysis of deprivation trajectories, their determinants and associated health impact will inform targeted interventions that promote social mobility and improved health.

Objective and Approach Using census returns from three waves of NILS (1991, 2001, 2011) linked with mortality data, we examined morbidity/mortality outcomes by socio-economic disadvantage over time (using an individual-level deprivation index derived from educational attainment, social class, housing tenure and household car availability at each census). These were combined to generate two indicators of Intercensal social mobility: measuring no change, and upward/downward mobility between censuses. The relationship between mobility (2001-2011) and (separately) self-reported mental ill-health (MIH) at the 2011 Census and all-cause mortality (2011-2015) were examined using logistic regression and Cox PH modelling respectively. Results Population comprised 288,262 individuals aged 25-74 in 2011, recording 19,318 deaths (2011-2015) and 23,959 (8.3%) reporting MIH. MIH: those with no intercensal mobility followed the standard pathway associated with persisting disadvantage (comparing with the most advantaged the least advantaged recorded OR=16.13:95%CI=13.50,19.28); and while both the upwardly and downwardly mobile generally recorded higher ORs than those consistently most advantaged, the magnitude of ORs increased with social distance traversed; and ORs for downward mobility were consistently higher than with upward mobility. Patterns associated with all-cause mortality were similar. Conclusions This suggests: upward mobility retains something of the social patterning pertaining in social disadvantage levels left behind; downward mobility may be connected to ongoing health issues. Poor health outcomes remain strongly associated with socio-economic circumstance. Implications Research focusing on relationship between social mobility, disadvantage and health outcomes in NI is limited: access to more precise administrative data will enhance possibilities associated with evidence-based policy formation.

Objective Over recent decades, there has been a noticeable increase in the prescription of antidepressant medications, particularly among older adults. This study examines the relationship between health outcomes and patterns of antidepressant use among older adults in Northern Ireland (NI). Approach Participants included all (General Practitioner) GP-registered hospital patients aged fifty-five years and above on 01/01/2010 (n =395,872). Administrative data linkage included demographic information (age, sex; urbanicity); data on antidepressant use from the NI Enhanced Prescribing Database (EPD); and hospital patient admissions/discharges. Repeated measures latent class analysis (RMLCA) identified patterns of antidepressant use (2010 to 2020) in relation to the association between these patterns and health-related outcomes in 2021. Results RMLCA identified four latent classes : long-term antidepressant use (17.4%); decreasing antidepressant use (7.1%); increasing antidepressant use (8.4%); no-antidepressant use (67.1%). Those in the long-term and increasing antidepressant use’ classes had the highest average number of hospital visits and recorded chronic conditions in 2021. Conclusion Findings show that two distinct subgroups (comprising 26% of the hospital population) were disproportionately impacted by increased antidepressant prescription rates. Because of their increased likelihood of experiencing higher ill-health, these people are crucial targets for additional psychosocial support. Implications Analyses of this kind emphasize the importance of widening access to administrative data, enabling researchers to identify and examine at-risk groups allowing more targeted policymaking to better address their needs. Data for this project was provided by the HSC Honest Broker Service; any views or opinions presented are solely those of the author.

Objective Adolescence is a vulnerable period for onset of depression. Socioeconomic deprivation may elevate the risk of depression. We explored the risk of depression in early adulthood in relation to deprivation during adolescence. Approach 97,561 individuals aged 10-14 years were grouped at baseline (2010) using small-area indicator of area-level deprivation (measured in quintiles) and linked with yearly antidepressant prescriptions (2010–2021). A logistic random-intercept multilevel model estimated the longitudinal trajectory of yearly antidepressant prescriptions (2010-2021) between deprivation quintiles in 2010, adjusting for sex and age at baseline. Results In 2010, the marginal probability of receiving antidepressants for an average young person differed little between those living in the most (0.0028: 95%CI=0.0025,0.0032) and least (0.0027: 0.0023,0.0032) deprived areas (p=0.75). By 2021, the marginal probability had increased more for those who lived in the most deprived areas in 2010 (0.191: 0.187,0.195) compared to those who lived in the least deprived areas in 2010 (0.140: 0.135,0.145)(p

Abstract Background Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people’s homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness. Methods ACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners’ experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is ‘successful rehabilitation’ defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months. Discussion The ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services. Trial registration ISRCTN17381762 retrospectively registered.

Introduction University students are one of the most vulnerable populations for anxiety disorders worldwide. In Northern Ireland, anxiety disorders appear to be more common among the university student population due to the population demographics across the region. Despite the need, these students show less inclination to access the widely available on-campus well-being services and other external professional services. Digital cognitive–behavioural therapy (CBT) aims to bridge this gap between the need for psychological help and access to it. However, challenges such as limited reach, low adoption, implementation barriers and poor long-term maintenance are mainstay issues resulting in reduced uptake of digital CBT. As a result, the potential impact of digital CBT is currently restricted. The proposed intervention ‘Cerina’ is a scalable CBT-based mobile app with an interactive user interface that can be implemented in university settings if found to be feasible and effective.Methods and analysis The study is a single-blind pilot feasibility randomised controlled trial aiming to test the feasibility and preliminary effects of Cerina in reducing Generalised Anxiety Disorder (GAD) symptoms. Participants are 90 Ulster University students aged 18 and above with self-reported GAD symptoms. They will be allocated to two conditions: treatment (ie, access to Cerina for 6 weeks) and a wait-list control group (ie, optional on-campus well-being services for 6 weeks). Participants in the wait-list will access Cerina 6 weeks after their randomisation and participants in both conditions will be assessed at baseline, at 3 (mid-assessment) and 6 weeks (postassessment). The primary outcome is the feasibility of Cerina (ie, adherence to the intervention, its usability and the potential to deliver a full trial in the future). The secondary outcomes include generalised anxiety, depression, worry and quality of life. Additionally, participants in both conditions will be invited to semistructured interviews for process evaluation.Ethics and dissemination Ethical approval for the study has been granted by the Ulster University Research Ethics Committee (ID: FCPSY-22-084). The results of the study will be disseminated through publications in scientific articles and presentations at relevant conferences and/or public events.Trial registration number NCT06146530.

Objective There is a dearth in suicide literature addressing the impact on general practitioners (GPs) of losing a patient. We aimed to examine the personal and professional impact as well as the availability of support and why GPs did or did not use it.Design A qualitative study using one-to-one interviews with participants recruited using snowball sampling.Setting The study was conducted in a primary care setting.Participants Interviews were held with 19 GPs within primary care in Northern Ireland.Results GPs are impacted both personally and professionally when they lose a patient to suicide, but may not access formal help due to commonly held idealised notions of a ‘good’ GP who is regarded as having solid imperturbability. Fear of professional repercussions also plays a major role in deterring help-seeking.Conclusions There is a need for a systemic culture shift within general practice which allows doctors to seek support when their physical or mental health require it. This may help prevent stress, burnout and early retirement.

There is growing evidence on the prevalence and impact of loneliness, particularly among older people. However, much less is known about the personal origins of loneliness and how it persists, or not, over an individual’s life course. This study aimed to increase understanding of the personal experiences of loneliness among older adults across the life course. Central to this study was giving voice to the participants and allowing them to define loneliness, what it meant to them, and how it affected them throughout their lives. This qualitative study employed 18 life story interviews with older adults attending a mental health service. We explored their personal experiences of loneliness and the situations and factors associated with loneliness across the life course. We identified three distinct typologies of loneliness: those who experienced (1) chronic loneliness since childhood, (2) chronic loneliness after a life-changing event in midlife, and (3) loneliness which remained situational/transitional, never becoming chronic. This study found the seeds of chronic life course loneliness are often determined in childhood. Early detection and intervention may prevent situational loneliness from becoming chronic. More research is needed from a life course approach to help understand and address the causes and consequences of loneliness.

BackgroundA growing number of studies have suggested that adolescents’ prosocial behavior can protect against depression and anxiety. It is known that anxiety and depression are often comorbid. However, it remains unclear if when depression is present, prosocial behavior remains protective against anxiety, and if when anxiety is present, prosocial behavior remains protective against depression. The purpose of this study was to determine the association of anxiety and depressive with prosocial behavior.MethodsA large representative sample of middle-school students was recruited for a cross-sectional study and completed standardized instruments (the Children’s Depression Inventory (CDI), Screen for Child Anxiety Related Emotional Disorders–Child version (SCARED-C), and Strengths and Difficulties Questionnaire (SDQ)). We used structural equation modeling (SEM) to examine the protective effect of prosocial behavior against anxiety when depression was present.ResultsA survey of 3,510 students was conducted, and the final analysis included 3,169 students, comprising 1,616 boys (51.0%) and 1,553 girls (49.0%), with a mean age of 13.09 years (SD = 1.31, range 11–16).The prevalence rates of anxiety and depression in early adolescents were 31.6 and 16.7%, respectively. More than two-thirds of depressed adolescents had comorbid anxiety, while more than one-third of anxious adolescents had comorbid depression. Regression models showed that compared with depressed adolescents, adolescents without depressive symptoms exhibited a significant negative correlation between prosocial behaviors and anxiety and depression (β = −0.01, p > 0.01, β = −0.06, p > 0.01; β = −0.11, p < 0.01, and β = −0.17, p < 0.01). There was no difference in the relationship between prosocial behavior and depression between anxious and non-anxious adolescents (p > 0.05).ConclusionAnxiety and depression are common in adolescence and are often comorbid disorders. However, the comorbidity is not symmetrical. Specifically, the protective effect of prosocial behavior against anxiety is weaker in depressed adolescents. Findings are discussed in light of related research and theory, and insights for intervention programs and future research are presented.

Objective To identify service-provided information needs among dermatological caregivers of patients living with ichthyosis.Design This is the first online international qualitative study to explore caregiver-reported service-provided information needs, using transnational focus groups (n=6), individual interviews (n=7) and in-depth emails (n=5). NVivo facilitated the coding process and Framework Analysis was applied.Setting Caregivers were recruited through two online ichthyosis support groups and resided across 10 countries and 5 continents (USA, Greece, Netherlands, Ireland, UK, Canada, India, Philippines, Switzerland and Australia).Participants A purposive sample of 8 male and 31 female caregivers participated (mean age range 35–44 years). Participants were aged 18 years old or older and fluent in English. Participants cared for a total of 46 children (1:1 ratio for child gender and clinical classification of disease severity). Participants represented all stages along the care continuum, including neonatal intensive care unit and bereavement.Results This study advances understanding of how to optimise information-sharing across hospital, community and online settings at three points along the care continuum (screening, active caregiving and survivorship). Timely, personalised and appropriate service-provided information support was considered key in influencing the self-efficacy, coping ability and psychosocial well-being of both the caregiver and their child. The modification of information support, through feedback loops, can result in a different bidirectional psychosocial impact for the caregiver and the affected child.Conclusion Our findings provide a novel insight into how existing gaps between caregiver expectations and needs, in terms of information support, can be addressed. As information support is a modifiable factor, improved healthcare education around these themes should become an urgent public health matter to inform future educational and psychosocial interventions.

Objectives In this study, we seek to explore the relationship between adolescent mental well-being, religion and family activities among a school-based adolescent sample from Northern Ireland.Setting The Northern Ireland Schools and Wellbeing Study is a cross-sectional study (2014–2016) of pupils in Northern Ireland aged 13–18 years.Participants 1618 adolescents from eight schools participated in this study.Outcomes measures Our primary outcome measure was derived using the Warwick-Edinburgh Mental Wellbeing Scale. We used hierarchical linear regression to explore the independent effects of a range of personal/social factors, including religious affiliation, importance of religion and family activities.Results In fully adjusted models, older adolescents and females reported lower mental well-being scores—for the year-on-year increase in age β=−0.45 (95% CI=−0.84, –0.06), and for females (compared with males) β=−5.25 (95% CI=−6.16, –4.33). More affluent adolescents reported better mental well-being. No significant differences in mental well-being scores across religious groups was found: compared with Catholics, Protestant adolescents recorded β=−0.83 (95% CI=−2.17, 0.51), other religious groups β=−2.44 (95% CI=−5.49, 0.62) and atheist adolescents β=−1.01 (95% CI=−2.60, 0.58). The importance of religion in the adolescents’ lives was also tested: (compared with those for whom it was not important) those for whom it was very important had better mental well-being (β=1.63: 95% CI=0.32, 2.95). Higher levels of family activities were associated with higher mental well-being: each unit increase in family activity produced a 1.45% increase in the mental well-being score (β=0.78: 95% CI=0.67, 0.90).Conclusions This study indicates that non-religious adolescents may have lower mental well-being scores when compared with their more religious peers, irrespective of religious denomination. This may relate to both a sense of lack of firm identity and perceived marginalisation. Additionally, adolescents with poor family cohesion are more vulnerable to poor mental well-being.

Abstract Background Poor parental bonding in childhood has been associated with loneliness in younger populations. Whether these associations persists into middle and older adulthood is unclear. Additionally, given the overlapping relationship between loneliness and social isolation we sought to explore the role of social isolation in any associations present i.e. are those reporting worse parental bonding lonely due to less connections or are they more likely to be lonely regardless of isolation. Methods Analysis of a nationally representative longitudinal sample of adults aged 50 and over from the English Longitudinal Study of Ageing was undertaken. The current analysis was based on data for core participants across waves 3[2006/7] to 8[2016/17] with missing data across waves leading to analytical samples ranging from 4384 to 5173. Multivariate adjusted multinomial regression models were used to assess associations between parental bonding [PBI], isolation [score derived from data on living alone, frequency of contact with friends, family and children, and whether or not participate in social organisations] and loneliness [R-UCLA]. Results Parental bonding scores were associated with later life loneliness according to overall PBI score [RRR .93 95%CI .92-.95], care [RRR .90 95%CI .88-.92] and overprotection [RRR 1.11 95%CI 1.08–1.14] subscale scores as well as when separated into maternal and paternal scores, with effects larger in relation to chronic loneliness. Parental bonding scores were also associated with isolation in later life, with the exception of maternal overprotection which was non-significant. The addition of isolation to the loneliness models however had no impact on associations indicating that isolation is not a mediator of the association between parental bonding and later life loneliness. Conclusions Associations between parental bonding and loneliness do persist into middle and older adulthood and were in line with hypothesis stronger for more chronic loneliness. Isolation did not explain these associations and those reporting more negative parental bonds were more likely to be lonely regardless of isolation.

Abstract Background Interventions designed to increase mental health awareness in sport have grown substantially in the last 5 years, meaning that those involved in policy, research and intervention implementation are not fully informed by the latest systematic evaluation of research, risking a disservice to healthcare consumers. Hence, our aim was to update a 2017 systematic review that determined the effect of sport-specific mental health awareness programmes to improve mental health knowledge and help-seeking among sports coaches, athletes and officials. We extended the review to incorporate parents as a source of help-seeking and report the validity of outcome measures and quality of research design that occurred since the original review. Methods Sport-specific mental health awareness programmes adopting an experimental or quasi-experimental design were included for synthesis. Five electronic databases were searched: Psychinfo, Medline (OVID interface), Scopus, Cochrane and Cinahl. Each database was searched from its year of inception to June 2020. As all of the outcomes measured were derived from psychometric scales, we observed statistically significant quantitative effects on the basis of p < .05, and a small, medium or large effect size as d = .2, .5 or .8, respectively. Risk of bias was assessed using the Cochrane and QATSQ tools. Results Twenty-eight articles were included from the 2048 retrieved, eighteen additional articles since the original review. Eighteen studies targeted athletes, five with coaches, one sport officials (i.e. referees), one ‘at-risk children’ and three with parents. One of the studies was a combination of athletes, coaches and parents. In terms of study outcomes, health referral efficacy was improved in seven studies; twelve studies reported an increase in knowledge about mental health disorders. Proportionally, higher quality research designs were evident, as three of ten studies within the previous review did not demonstrate a high risk of bias, whereas thirteen of the eighteen additional studies did not display a high risk of bias. However, only one study included a behaviour change model in both the programme design and evaluation. Conclusions Our updated systematic review provides evidence of the benefits of mental health awareness interventions in sport; these benefits are mainly for athletes and show improvements in the methodological design of recent studies compared to the first review. There was also evidence of the extension of programme delivery to parents. In conclusion, researchers, practitioners and policy makers should consider methodological guidance and the application of theory when developing and evaluating complex interventions. Systematic review registration PROSPERO CRD42016040178

Abstract Background People with severe mental illness (SMI) die prematurely, mostly due to preventable causes. Objective To examine multimorbidity and mortality in people living with SMI using linked administrative datasets. Method Analysis of linked electronically captured routine hospital administrative data from Northern Ireland (2010–2021). We derived sex-specific age-standardised rates for seven chronic life-limiting physical conditions (chronic kidney disease, malignant neoplasms, diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure, myocardial infarction, and stroke) and used logistic regression to examine the relationship between SMI, socio-demographic indicators, and comorbid conditions; survival models quantified the relationship between all-cause mortality and SMI. Results Analysis was based on 929,412 hospital patients aged 20 years and above, of whom 10,965 (1.3%) recorded a diagnosis of SMI. Higher likelihoods of an SMI diagnosis were associated with living in socially deprived circumstances, urbanicity. SMI patients were more likely to have more comorbid physical conditions than non-SMI patients, and younger at referral to hospital for each condition, than non-SMI patients. Finally, in fully adjusted models, SMI patients had a twofold excess all-cause mortality. Conclusion Multiple morbidities associated with SMI can drive excess mortality. While SMI patients are younger at referral to treatment for these life-limiting conditions, their relatively premature death suggests that these conditions are also quite advanced. There is a need for a more aggressive approach to improving the physical health of this population.

BackgroundWhile evidence has emerged highlighting the potential benefits of the eye as a window to the central nervous system, research on severe mental illness (SMI) and eye health is rare.AimsWe examine the association of SMI with a range of ophthalmic health outcomes, and whether any relationship is modified by age.MethodsWe used linked administrative data from general practitioner (GP), hospital and ophthalmic records to examine receipt of any Health and Social Care (HSC) eye-test; and (based on eligibility recorded for a sight test) any glaucoma, any diabetes, and any blindness among the Northern Ireland (NI) hospital population between January 2015 and November 2019 (N = 798,564).ResultsWhen compared with non-SMI patients, those with SMI recorded a higher prevalence of having had a sight test, diabetes, and blindness. In fully adjusted logistic regression models, higher likelihood of an eye-test and diabetes (OR = 1.71: 95%CI = 1.63, 1.79 and OR = 1.29: 1.19, 1.40 respectively); and lower likelihood of glaucoma remained (OR = 0.69: 0.53, 0.90). Amongst persons with SMI there was evidence that the likelihood of having had an eye-test was lower in the older age-groups.ConclusionOur study provides new evidence on ophthalmic health inequalities associated with SMI. While the study has immediate relevance to its NI context, we believe it is generalizable to wider UK health concerns. We emphasize the need for more research of this type, using large linkable electronic administrative databases to further our understanding of both health inequalities associated with SMI and poor eye health, and health outcomes in general.

Introduction Ichthyoses comprise a heterogenous group of rare genetic skin disorders that involves the entire skin surface, often with additional syndromic features, and pose many clinical challenges. Without curative intervention, the mainstay of life-long symptom management is supportive in nature and can remain the responsibility of the caregiver. Although impact on the wider family is considered an important outcome of policies and services, there is a lack of caregiver consensus on what outcome domains to measure to fully assess the impact of ichthyosis on the patient and the caregiver. This project aims to identify a set of core outcome domains towards a core outcome set for ichthyosis that can measure all relevant concepts of ichthyosis in clinical practice, service delivery and research.Methods and analysis Following the COMET (Core Outcome Measures in Effectiveness Trials) initiative, this project will employ a mixed-method study design which was developed using public and patient involvement and an international multidisciplinary expert group (clinical experts, patients and their representatives, policymakers, researchers and service providers). Experts by experience, or caregivers, will be recruited through online ichthyosis support groups. Phase one will focus on item generation and involve: (1) a systematic literature review, (2) a multimethods international qualitative study with ichthyosis caregivers and (3) co-development of items for an e-survey. Phase two, item refinement, will employ a novel four-pronged consensus approach: (1) an e-Delphi survey, (2) statistical analysis of e-Delphi survey results, (3) online qualitative feedback and (4) an online consensus discussion. All methodological considerations will be clearly linked with each Core Outcome Set-STAndards for Developing recommendation.Ethics and dissemination Research Ethics Committee approval obtained from the School of Psychology, Ulster University (UK)(Ref:REC/20/0004). Results will be presented in published international peer-reviewed journals, at scientific meetings and support groups.Registration COMET database (January 2019).

Introduction While chronic disease is a risk factor for dementia (Shang et al., 2020) studies addressing multimorbidity and dementia risk are limited. Multimorbidity leads to steeper dementia progression (Bauer, 2014; Haaksma, 2019) impacting cognitive dysfunction, cognitive decline and impairment (Wei, 2020; Vassilaki, 2015). Multimorbidity has generally been examined using a dose- response disease count, something cited as impractical for clinicians due to information deficits on identifying disease specific pathways (Whitty, 2020). Thus, differentiating disease clusters and dementia risk will provide insight into the pathophysiology of dementia, while informing priority targets for early intervention, potentially reducing burden and secondary care costs. Aim To investigate dementia risk and mortality in older adults with different disease patterns, characteristics of hospital admissions, medication use and the role of locale of residence. Data linkage and analysis We used national data defined by the NHAIS, including basic demographics for all patients aged fifty-five plus and registered with a GP in Northern Ireland. The linked data comprised: Patient Admissions and Discharges (from 2013-2021); Electronically captured prescribing data, area-type of usual residence; Multiple Deprivation Indicators; and GRO mortality data (including cause of death). We identified multimorbidity through validated algorithms for ICD-10 coding of thirty morbidities in administrative hospital diagnostics data (Tonelli et al., 2019). The same data identified dementia-free patients at baseline. Latent Class Analysis assigned patient groups by the patterning of multimorbidity states, following them through the study period, with analysis in relation to subsequent diagnoses of both clinical dementia and mortality. As age has a potential modifier effect we tested through age group stratified analyses. A series of multinomial logistic regression models further examine (for the multimorbidity sub-groups of interest) risks associated socio-demographic, socio-economic, medication use and household indicators at the individual, family and area level. Results Multimorbidity occurs in two thirds, approximately, of this hospital population of older adults. By age sixty-five years, most people are multimorbid. We identify subgroups of multimorbidity associated with dementia onset and mortality, combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are highlighted as higher-risk conditions for increased dementia incidence and mortality. Greater disease burden is associated with frequent healthcare service use, medication use and is more common in the most socioeconomically deprived, compared with the least deprived. Discussion Evidence on multimorbidity patterns and dementia is limited (Grande, 2021). Our study suggests that people with combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are associated with increased risks for dementia and socio demographic and economic circumstances further increase this risk. Overlapping combinations comprising chronic kidney disease + hypertension, or diabetes + hypertension, were a significant proportion of total secondary care costs for patients with multimorbidity; combinations comprising chronic heart failure + chronic kidney disease + hypertension had the highest proportion of total cost from potentially preventable emergency admissions (Stokes et al., 2021). Our finding support the body and mind connection in dementia development. Thus, we note that cardiovascular health is associated with dementia (Grande, 2021). Often described as a heart-brain connection, cardiovascular disease leads to higher dementia risk due to a number of mechanisms including but not limited to chronic inflammation (Grande, 2021). Identifying such high-risk groups will facilitate tailored interventions for dementia prevention and the reduction of healthcare use and costs.

Objectives Oral health of people with severe mental illness (SMI) remains an important public health issue with some evidence pointing suboptimal dental health outcomes. We test the hypotheses that individuals with SMI have lower contact with dental services and higher levels of fillings and extractions. We also examine effect modification by age. Approach We used linked administrative data from general practitioner (GP) records, hospital admissions data and dental payment system data to examine dental service use and treatments (extractions, fillings, crowns and x-rays) among the Northern Ireland hospital population between January 2015 and November 2019 (N=798,564). Logistic regression examined the association of SMI with dental service use and treatments, controlling for socio-demographic characteristics. In a further series of models, the interaction of SMI and age-group was examined. Results An estimated 1.2% (9,656) recorded an SMI diagnosis from hospital records at some point during follow-up. Over two-thirds (67.2%) of the non-SMI hospital population received any dental treatment compared with 62.2% of persons SMI-diagnosed. After adjusting for available socio-demographic characteristics, analysis indicated lower levels of dental service use (OR=0.80, 95% CI=0.77, 0.84), including lower likelihood of fillings (OR=0.81, 0.77, 0.84) and x-rays (OR=0.77, 0.74, 0.81), but higher levels of extractions (OR=1.23, 1.18, 1.29) among patients with SMI. We also found effect modification by age-group: while older age was generally associated with higher likelihood of extractions and crowns, interaction analysis points to lower likelihood of all four dental treatments among older individuals with SMI. Conclusions Our findings of lower engagement with dental services, lower levels of remedial treatments and higher levels of tooth loss raise concerns about availability, access, and promotion of routine dental care for people with SMI. There is a need for improved understanding of barriers to treatment and development of psychoeducational interventions.

Background: Building 'key skills' may help prevent the development of challenging behaviour in children with an intellectual disability. The aim of this paper was to extend the current limited evidence in this area. Method: We undertook two studies with children with an intellectual disability in school settings: (1) a cross-sectional replication study exploring the relationship between 'key skills' and challenging behaviour. (2) a longitudinal study follow-up exploring change in 'key skill' levels and challenging behaviour. Results: The replication study recruited 74 participants, those scoring lowest in 'key skill' had a 94% chance of having challenging behaviour; those with the highest scores had a 6% chance. The follow-up study recruited 39 participants, we found a significant increase in children's 'key skill' level (p < 0.001) and a decrease in their challenging behaviour (p = 0.046). Conclusion: Building 'key skills' in children with an intellectual disability may help reduce or prevent challenging behaviour.

Abstract Background More people living into old age with dementia. The complexity of treatment and care, particularly those with multiple health problems, can be experienced as disjointed. As part of an evaluation of a ‘healthcare passport’ for people living with dementia we undertook a realist review of communication tools within health and social care for people living with dementia. Aims To explore how a ‘healthcare passport’ might work in the ‘real world’ of people living with dementia through a better understanding of the theoretical issues related to, and the contextual issues that facilitate, successful communication. Methods A realist review was considered the most appropriate methodology to inform the further development and evaluation of the healthcare passport. We undertook a purposive literature search related to communication tools to identify (a) underlying programme theories; (b) published reports and papers on their use in various healthcare settings; (c) evidence on barriers and facliitators of their use. Results Communication tools were noted as a way of improving communication and outcomes through: (1) improvement of service user autonomy; (2) strengthening the therapeutic alliance; and (3) building integrated care. However, while intuitively perceived to of benefit, evidence on their use is limited and key barriers to their acceptance and use include: (1) difficulties in clearly defining purpose, content, ownership and usage; (2) understanding the role of family caregivers; and (3) preparation among healthcare professionsals. Conclusion Patient-held communication tools may be helpful to some people living with dementia but will require considerable preparation and engagement with key stakeholders.

Abstract Background Older people are vulnerable to sustained high levels of psychosocial distress following a crime. A cognitive behavioural therapy (CBT)-informed psychological therapy, the Victim Improvement Package (VIP) may aid recovery. The VIP trial aims to test the clinical and cost-effectiveness of the VIP for alleviating depressive and anxiety symptoms in older victims of crime. Methods/design People aged 65 years or more who report being a victim of crime will be screened by Metropolitan Police Service Safer Neighbourhood Teams within a month of the crime for distress using the Patient Health Questionnaire-2 and the Generalised Anxiety Disorder-2. Those who screen positive will be signposted to their GP for assistance, and re-screened at 3 months. Participants who screen positive for depression and/or anxiety at re-screening are randomised to a CBT informed VIP added to treatment as usual (TAU) compared to TAU alone. The intervention consists of 10 individual 1-h sessions, delivered weekly by therapists from the mental health charity Mind. The primary outcome measure is the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI), used as a composite measure, assessed at 6 months after the crime (post therapy) with a 9-month post-crime follow-up. Secondary outcome measures include the EQ-5D, and a modified Client Service Receipt Inventory. A total of 226 participants will be randomised VIP:TAU with a ratio 1:1, in order to detect a standardised difference of at least 0.5 between groups, using a mixed-effects linear-regression model with 90% power and a 5% significance level (adjusting for therapist clustering and potential drop-out). A cost-effectiveness analysis will incorporate intervention costs to compare overall health care costs and quality of life years between treatment arms. An embedded study will examine the impact of past trauma and engagement in safety behaviours and distress on the main outcomes. Discussion This trial should provide data on the clinical and cost-effectiveness of a CBT-informed psychological therapy for older victims of crime with anxiety and/or depressive symptoms and should demonstrate a model of integrated cross-agency working. Our findings should provide evidence for policy-makers, commissioners and clinicians responding to the needs of older victims of crime. Trial registration International Standard Randomised Controlled Trials Number, ID: ISRCTN16929670 . Registered on 3 August 2016.

Abstract Background Keeping people living with advanced dementia in their usual place of residence is becoming a key governmental goal but to achieve this, family carers and health care professionals must negotiate how to provide optimal care. Previously, we reported a realist analysis of the health care professional perspective. Here, we report on family carer perspectives. We aimed to understand the similarities and differences between the two perspectives, gain insights into how the interdependent roles of family carers and HCPs can be optimised, and make recommendations for policy and practice. Method Qualitative study using a realist approach in which we used the criteria from guidance on optimal palliative care in advanced dementia to examine key contexts, mechanisms and outcomes highlighted by family carers. Results The themes and views of family caregivers resonate with those of health care professionals. Their overlapping anxieties related to business-driven care homes, uncertainty of families when making EOL decisions and the importance of symptom management referring to contexts, mechanisms and outcomes, respectively. Contexts specific to family carers were ad hoc information about services, dementia progression and access to funding. Not all family carers identified dementia as terminal, but many recognised the importance of continuity of care and knowing the wishes of the person with dementia. New mechanisms included specific resources for improving EOL care and barriers to discussing and planning for future care. Family carers identified the importance of comfort, being present, the meeting of basic care needs and feeling the right decisions have been made as good outcomes of care. Conclusions Family carers and health care professionals share similar concerns about the challenges to good EOL dementia care. Better understanding of the effects of dementia at the advanced stages would improve confidence in EOL care and reduce uncertainty in decision making for family carers and health care professionals.

Cardiovascular disease (CVD) is the world’s leading cause of mortality. There is significant interest in using Artificial Intelligence (AI) to analyse data from novel sensors such as wearables to provide an earlier and more accurate prediction and diagnosis of heart disease. Digital health technologies that fuse AI and sensing devices may help disease prevention and reduce the substantial morbidity and mortality caused by CVD worldwide. In this review, we identify and describe recent developments in the application of digital health for CVD, focusing on AI approaches for CVD detection, diagnosis, and prediction through AI models driven by data collected from wearables. We summarise the literature on the use of wearables and AI in cardiovascular disease diagnosis, followed by a detailed description of the dominant AI approaches applied for modelling and prediction using data acquired from sensors such as wearables. We discuss the AI algorithms and models and clinical applications and find that AI and machine-learning-based approaches are superior to traditional or conventional statistical methods for predicting cardiovascular events. However, further studies evaluating the applicability of such algorithms in the real world are needed. In addition, improvements in wearable device data accuracy and better management of their application are required. Lastly, we discuss the challenges that the introduction of such technologies into routine healthcare may face.

Objective Health and Social Care (HSC) workers are at high risk of job-related stress, burnout and mental ill-health. This study examines differences in self-reported mental health and psychotropic medication uptake across HSC occupational groups. Method Northern Ireland (NI) data linkage study of people working in the Health and Care sector, aged between twenty and sixty-four years, enumerated at the 2011 Northern Ireland Census and living in private households, and their uptake of prescribed psychotropic medications during 2011-2012 (using data derived from routine electronically captured information on prescriptions issued within the NHS and linked at an individual level using a NI-specific Health and Care key identifier). Comparing HSC workers with all those professionals not involved in HSC occupations, we used multinomial logistic regression to examine (a) self-reported chronic mental illness and (b) uptake of psychotropic medication by occupational groups adjusting for age, sex and socio-demographic circumstance. Results When compared against other professionals highest risks for mental health problems (associated with psychotropic prescription uptake) were associated with nursing/midwifery (OR = 1.25: 95{%}CI = 1.17-1.33; OR = 1.84: 1.58-2.15 for females and males respectively), welfare (OR = 1.34: 1.21-1.48; OR = 1.71: 1.44-2.03) and formal caregiving roles (OR = 1.42: 1.31-1.53; OR = 1.70: 1.50-1.91), again for females/males respectively). These higher risk professions record notable increases in psychotropic medication use. Conclusion Working in the Health and Social Care sector, irrespective of gender, may be more stressful than other jobs. Additionally, self-reported mental ill-health and psychotropic medication treatment both appear to be associated with social class inequity.

Background: Few have explored associations between loneliness and healthcare use independent of health and health behaviors. Recent indication of gender effects also requires validation across health service and cultural settings. We investigated the associations among loneliness, health and healthcare use (HCU) in older adults including stratification to investigate whether associations differed by gender.Methods: Secondary analysis of a nationally representative sample of 8,309 community-dwelling adults aged 50 and over from the Northern Ireland Cohort for the Longitudinal Study of Aging. Primary outcomes were: self-reported General Practice (GP) and emergency department (ED) visits in past year. Negative binomial and logistic regression analysis were used to investigate associations between loneliness and HCU, later adjusting for potential confounders (health and health behaviors).Results: Loneliness was consistently positively associated with both GP and ED visits (with IRRs ranging from 1.10 to 1.49 for GP visits, 1.16 to 1.98 for ED visits and ORs ranging from 1.13 to 1.51 for reporting at least one ED visit). With addition of health and health behaviors, all associations between loneliness and HCU became non-significant, excepting a small independent association between UCLA score and GP visits [IRR 1.03 (95% CI 1.01–1.05)]. Stratification of models revealed no gender effects.Conclusion: All but one association between loneliness and HCU became non-significant when health and health behaviors were included. The remaining association was small but implications remain for health service resources at population level. No gender effects were present in contrast to recent findings in the Republic of Ireland. Further studies on gender, loneliness and healthcare use needed.

AbstractBackground.To assess the prevalence of autism traits in individuals accessing gender affirming treatments, we conducted a cross-sectional survey in the regional specialist gender services in Northern Ireland.Methods.One hundred and twenty-three individuals (38 adolescents and 69 adults) currently attending or who previously attended specialist gender services in Northern Ireland were recruited. Fifty-six individuals assigned male at birth (AMAB) and 66 individuals assigned female at birth (AFAB) took part in the study. Main outcome measures: Autism Quotient (AQ), Cambridge Behavior Scale (EQ), and RAADS-14.Results.Autism trait prevalence rates of 19.5% (AQ); 25.4% (RAADS-14); and 35.8% (poor empathy traits). A combined measure comprising all three provided a prevalence of 17.2%. There were no mean differences in the scores between AMAB (assigned male at birth) individuals and AFAB (assigned female at birth) individuals.Conclusions.Autism traits present additional challenges during the assessment and treatment of individuals with gender dysphoria. Autism screening tools can aid in the identification of individual with additional needs.

Background While employment in general promotes positive health and wellbeing, a number of studies show disparities in mental health across occupational groupings (Bell et al., 2014; Stansfield et al. 2011). However, definitive studies to allow estimation of prevalence and risk across a range of occupation types require large population sub-groups and common measures of mental health. Aim We hypothesise: (1) we will detect differences in the prevalence of Common Mental Disorder (CMD) across occupational groupings; and (2) risk of CMD across occupation types is moderated by family demands. Methods Using linked administrative data we examine CMD among the Northern Ireland (NI) adult population across Standard Occupational Classifications (SOCs). We also examine the influence of socio-demographic, socio-economic and health-related variables. Data is accessed through the Administrative Data Research Centre NI (ADRC-NI) and comprises the individual and household 2011 Census; Land and Properties Services data; Enhanced Prescribing Database and Multiple Deprivation Measures. Results Examination of nine major SOC groups shows the prevalence of any self-reported (SR) mental health condition was highest among ‘elementary trades and related occupations’ (24.63%) followed by ‘process, plant and machine operatives’ (23.65%). The risk of mental ill health among these groups remained elevated for both men and women after controlling for age, sex, marital status and educational attainment. Analyses based on the 90 sub-minor SOC groups shows that ‘textiles and garments trades’ workers had the highest prevalence of a SR mental health condition (36.15%). Logistic regression analyses shows that individuals with dependent children and informal caregiving responsibilities had lower risk of a SR mental health condition (OR=0.75, CI=0.73, 0.76 and OR=0.81, CI=0.79, 0.82 respectively). Conclusion Results presented in this abstract are based on preliminary analyses using self-reported mental health. Further analyses based on mental health prescription data will subsequently be undertaken and presented at the ADR conference.

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.

Abstract Background Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs. Methods Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients. Results Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision. Conclusions Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.

In the last decade, there has been a significant increase in the number of people diagnosed with dementia. With diminishing public health and social care resources, there is substantial need for assistive technology-based devices that support independent living. However, existing devices may not fully meet these needs due to fears and uncertainties about their use, educational support, and finances. Further challenges have been created by COVID-19 and the need for improved safety and security. We have performed a systematic review by exploring several databases describing assistive technologies for dementia and identifying relevant publications for this review. We found there is significant need for appropriate user testing of such devices and have highlighted certifying bodies for this purpose. Given the safety measures imposed by the COVID-19 pandemic, this review identifies the benefits and challenges of existing assistive technologies for people living with dementia and their caregivers. It also provides suggestions for future research in these areas.

Abstract 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

Abstract Background Many studies have examined the mental health of carers of people with dementia. Few have examined their experiences in the advanced stages of disease and into bereavement. We aimed to understand the experiences of carers during advanced dementia exploring the links between mental health and experiences of end of life care. Methods Mixed methods longitudinal cohort study. Thirty-five family carers of people with advanced dementia (6 at home, 29 in care homes) were recruited and assessed monthly for up to nine months or until the person with dementia died, then at two and seven months into bereavement. Assessments included: Hospital Anxiety and Depression Scale, Short Form 12 health–related quality of life, 22-item Zarit Burden Interview, Brief Coping Orientation to Problems Experienced, Inventory of Complicated Grief and Satisfaction with Care at End of Life in Dementia. Subsequently, 12 carers (34%) were bereaved and 12 undertook a qualitative interview two months after death; these data were analysed thematically. We analysed quantitative and qualitative data independently and then merged findings at the point of interpretation. Results At study entry psychological distress was high; 26% reached caseness for depression and 41% for anxiety and median complicated grief scores were 27 [IQR 22–37] indicating that on average 11 of the 16 grief symptoms occurred at least monthly. Physical health reflected population norms (mean = 50) and median burden scores were 17 [IQR 9–30]. Three qualitative themes were identified: the importance of relationships with care services, understanding of the progression of dementia, and emotional responses to advanced dementia. An overarching theme tying these together was the carer’s ability to control and influence end of life care. Conclusions While carers report high levels of psychological distress during advanced dementia, the experience of end of life care in dementia may be amenable to change with the provision of sensitive and timely information about the natural progression of dementia. Regular health status updates and end of life discussions can help families understand dementia progression and prepare for end of life. The extent to which our findings reflect practice across the UK or internationally warrants further investigation.

Abstract Background Deinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients. Methods We interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis. Results There were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement. Conclusions The findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.

Background Trials of psychological interventions for reducing agitation in people with dementia living at home have been unsuccessful. Aims To inform future interventions by identifying successful strategies of family carers with relatives with dementia and agitation living at home. Method Qualitative in-depth individual interviews were performed with 18 family carers. We used thematic analysis to identify emerging themes. Results Carers described initial surprise and then acceptance that agitation is a dementia symptom and learned to respond flexibly. Their strategies encompassed: prevention of agitation by familiar routine; reduction of agitation by addressing underlying causes and using distraction; prevention of escalation by risk enablement, not arguing; and control of their emotional responses by ensuring their relative's safety then walking away, carving out some time for themselves and using family and services for emotional and practical help. Conclusions These strategies can be manualised and tested in future randomised controlled trials for clinical effectiveness in reducing agitation in people with dementia living at home.

Background: Across England, around 60,000 people live in mental health supported accommodation: residential care, supported housing and floating outreach. Residential care and supported housing provide on-site support (residential care provides the highest level), whereas floating outreach staff visit people living in their own tenancies. Despite their abundance, little is known about the quality and outcomes of these services. Objectives: The aim was to assess the quality, costs and effectiveness of mental health supported accommodation services in England. The objectives were (1) to adapt the Quality Indicator for Rehabilitative Care (QuIRC) and the Client Assessment of Treatment scale for use in mental health supported accommodation services; (2) to assess the quality and costs of these services in England and the proportion of people who ‘move on’ to less supported accommodation without placement breakdown (e.g. to move from residential care to supported housing or supported housing to floating outreach, or, for those receiving floating outreach, to manage with fewer hours of support); (3) to identify service and service user factors (including costs) associated with greater quality of life, autonomy and successful move-on; and (4) to carry out a feasibility trial to assess the required sample size and appropriate outcomes for a randomised evaluation of two existing models of supported accommodation. Design: Objective 1 – focus groups with staff (n = 12) and service users (n = 16); psychometric testing in 52 services, repeated in 87 services (adapted QuIRC) and with 618 service users (adapted Client Assessment of Treatment scale). Objectives 2 and 3 – national survey and prospective cohort study involving 87 services (residential care, n = 22; supported housing, n = 35; floating outreach, n = 30) and 619 service users followed over 30 months; qualitative interviews with 30 staff and 30 service users. Objective 4 – individually randomised, parallel-group feasibility trial in three centres. Setting: English mental health supported accommodation services. Participants: Staff and users of mental health supported accomodation services. Interventions: Feasibility trial involved two existing models of supported accommodation: supported housing and floating outreach. Main outcome measures: Cohort study – proportion of participants who successfully moved to less supported accommodation at 30 months’ follow-up without placement breakdown. Feasibility trial – participant recruitment and withdrawal rates. Results: The adapted QuIRC [QuIRC: Supported Accomodation (QuIRC-SA)] had excellent inter-rater reliability, and exploratory factor analysis confirmed its structural validity (all items loaded onto the relevant domain at the > ± 0.3 level). The adapted Client Assessment of Treatment for Supported Accommodation had good internal consistency (Cronbach’s alpha 0.89) and convergent validity (rs = 0.369; p

Introduction: Many sport associations have responded to mental health issues in sport through the inclusion of self-management programs, such as mindfulness training, which may improve well-being through increasing one’s competence in self-regulating stressors. Yet, the mechanisms accounting such changes lack a theoretical basis, particularly in athletes.Aim: To determine the effect of a mental health intervention comprising a mindfulness program for promoting well-being, reducing stress, and increasing competence in mental health self-management. This is the first study among athletes to test the mechanisms of change in a mindfulness program using Self-Determination Theory (SDT).Methods: A 2 (groups) × 2 (time-point) non-randomized controlled trial was conducted, and between-groups baseline differences were firstly assessed. Two competing regression models assessing singular and serial indirect mediating mechanisms were conducted, in which mindfulness (Model 1) and competence satisfaction (Model 2) were both tested as primary and secondary mediators predicting change scores in stress and well-being. Demographic variables (i.e., gender, age) were controlled for in the analyses.Results: Two hundred and thirty-eight student athletes (mean age = 20.47 years, SD = 3.30, 57.6% = males) participated, with 108 in the intervention group who received an instructional workshop, and a home-directed mindfulness program comprising daily meditation sessions. No baseline differences were found between intervention and control groups. In Model 1, mindfulness was not directly enhanced by the intervention, subsequently resulting in no indirect effects on competence, stress and well-being. In Model 2, the intervention was directly related to positive changes in competence (β = 0.39, p < 0.05), subsequently resulting in indirect effects on mindfulness awareness (β = 0.07, p < 0.05), stress (β = −0.06, p < 0.05), and well-being (β = 0.05, p < 0.05). In addition, serial indirect effects for the intervention on stress were present through competence and mindfulness awareness in sequence (β = −0.02, p < 0.05), and; on well-being through competence, mindfulness awareness, and stress in sequence (β = 0.01, p < 0.05; R2 = 0.54).Conclusion: Mindfulness-based mental health interventions may be effective at reducing stress and promoting well-being in athletes, with the caveat that attention is given to the inclusion of mental health competence promotion in program design. However, it remains unclear whether increasing mindfulness itself can exert additional salutary effects. Our findings have an important bearing on how mindfulness programs are developed within athlete mental health interventions.

Background: Mental health supported accommodation services are implemented across England, usually organised into a ‘step-down’ care pathway that requires the individual to repeatedly move as they gain skills and confidence for more independent living. There have been no trials comparing the effectiveness of different types of supported accommodation, but two widely used models (supported housing and floating outreach) have been found to provide similar support. We aimed to assess the feasibility of conducting a large-scale trial comparing these two models.Methods: Individually randomised, parallel group feasibility trial in three regions of England (North London, East London, and Cheltenham and Gloucestershire). We aimed to recruit 60 participants in 15 months, referred to supported accommodation, randomly allocated on an equal basis to receive either a local supported housing or floating outreach service. We assessed referrals to the trial, participants recruited, attrition, time from recruitment to moving into either type of supported accommodation, and feasibility of masking. We conducted a process evaluation to examine our results further.Results: We screened 1,432 potential participants, of whom 17 consented to participate, with 8 agreeing to randomisation (of whom 1 was lost to attrition) and 9 participating in naturalistic follow-up. Our process evaluation indicated that the main obstacle to recruitment was staff and service user preferences for certain types of supported accommodation or for specific services. Staff also felt that randomisation compromised their professional judgement.Conclusions: Our results do not support investment in a large-scale trial in England at this time.Trial registration: UK CRN Portfolio database, Trial ID: ISRCTN19689576.Trial funding: National Institute of Health Research (RP-PG-0707-10093).

IntroductionDementia 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.MethodsAnalysis 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.ResultsRespondents (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.ConclusionPersonal 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.

Background and objectivesAgitation is common in people living with dementia especially at the end of life. We examined how staff interpreted agitation behavior in people with dementia nearing end of life, how this may influence their responses and its impact on the quality of care.Research designEthnographic study. Structured and semi-structured non-participant observations (referred to subsequently in this paper as "structured observations") of people living with dementia nearing the end of life in hospital and care homes (south-east England) and in-depth interviews with staff, conducted August 2015-March 2017.MethodsThree data sources: 1) detailed field notes, 2) observations using a structured tool and checklist for behaviors classed as agitation and staff and institutional responses, 3) staff semi-structured qualitative interviews. We calculated the time participants were agitated and described staff responses. Data sources were analyzed separately, developed continuously and relationally during the study and synthesized where appropriate.ResultsWe identified two main 'ideal types' of staff explanatory models for agitation: In the first, staff attribute agitated behaviors to the person's "moral judgement", making them prone to rejecting or punitive responses. In the second staff adopt a more "needs-based" approach in which agitation behaviors are regarded as meaningful and managed with proactive and investigative approaches. These different approaches appear to have significant consequences for the timing, frequency and quality of staff response. While these models may overlap they tend to reflect distinct organizational resources and values.ConclusionsCare worker knowledge about agitation is not enough, and staff need organizational support to care better for people living with dementia towards end of life. Positional theory may help to explain much of the cultural-structural context that produces staff disengagement from people with dementia, offering insights on how agitation behavior is reframed by some staff as dangerous. Such behavior may be associated with low-resource institutions with minimal staff training where the personhood of staff may be neglected.

Background The 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). Objectives The 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. Method The 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. Findings Preliminary 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. Conclusions Disability and functional impairment questionnaires can be effective tools to describe observed differences in mortality.

Background: The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap. Methods: The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses. Results: Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study. Conclusions: People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery. Main limitation: Our programme included only NHS, non-secure, inpatient mental health rehabilitation services. Trial registration: Current Controlled Trials ISRCTN25898179. Funding: The NIHR Programme Grants for Applied Research programme.

Objectives. Deinstitutionalization of long-term psychiatric patients produced various community-based residential care facilities. However, inner-city areas have many patients with severe mental illness (SMI) as well as deprivation, unemployment, and crime. This makes meeting their community needs complex. We undertook a needs assessment of service provision and consonance between service users’ evaluation of need and by care workers. Design. Cross-sectional study with random sample of SMI service users in four housing settings: rehabilitation units; high-supported; medium-supported; low-supported housing. Setting. London Borough of Haringey. Outcome Measures. 110 SMI service users and 110 keyworkers were interviewed, using Camberwell Assessment of Need; SF-36; Lancashire Quality-of-Life profile; demographic and clinical information. Results. People in “low-support” and “high-support” housing had similar symptom scores, though low support had significantly lower quality of life. Quality of life was positively predicted by self-reported mental-health score and negatively predicted by unmet-need score in whole sample and in medium-support residents. Residents’ and care-workers’ assessments of need differed considerably. Conclusions. Although patients’ housing needs were broadly met, those in low-supported housing fared least well. Attendance to self-reported mental health and unmet social needs to quality of life underpins planning of residential services for those with SMI. Social and personal needs of people in supported housing may be underestimated and overlooked; service providers need to prioritise these if concept of “recovery” is to advance.