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Background Many with an acute depressive disorder go on to develop chronic depression, despite ongoing care. There are few specifically designed interventions to treat chronic depression. DIALOG+, a technology-assisted intervention based on the principles of solution-focused therapy, may be beneficial. It has been shown to be effective as a treatment for patients with psychotic disorders, especially in regards to increasing quality of life. DIALOG+ was designed to be flexibly applied and not diagnosis-specific, aiming to structure communication and generate a personally-tailored care plan. This cluster randomised controlled trial (RCT) is part of a programme of research to adapt and test DIALOG+ for patients with chronic depression. Methods Patients will be eligible for the trial, if they have exhibited symptoms of depression or non-psychotic low mood for at least 2 years, have regular contact with a clinician and have a low subjective quality of life and moderate depressive symptoms. Clinicians, who routinely see eligible patients, will be recruited from a number of sites across NHS England. Clusters will have between 1 and 6 patients per clinician and will be randomised in a 1:1 ratio to either the intervention (DIALOG+) or active control group (treatment as usual + DIALOG scale). Clinicians in the intervention group are trained and asked to deliver the intervention regularly for 12 months. Active control participants receive treatment as usual and are asked to rate their satisfaction with areas of life and treatment on the DIALOG scale at the end of the clinical session. Approximately 112 clinician clusters will be recruited to reach a total patient sample size of 376. Clinical and social outcomes including costs are assessed at baseline and 3, 6 and 12 months post randomisation. The primary outcome will be subjective quality of life at 12 months. Discussion This definitive multi-site, cluster RCT aims to evaluate the clinical- and cost-effectiveness of DIALOG+ for people with chronic depression. If shown to be effective for this patient population it could be used to improve outcomes of mental health care on a larger scale, ensuring that patients with complex and co-morbid diagnoses can benefit. Trial registration ISRCTN11301686. Registered on 13 Jun 2019.

Background: Many with an acute depressive disorder go on to develop chronic depression, despite ongoing care. There are few specifically designed interventions to treat chronic depression. DIALOG+, a technology-assisted intervention based on the principles of solution-focused therapy, may be beneficial. It has been shown to be effective as a treatment for patients with psychotic disorders, especially in regards to increasing quality of life. DIALOG+ was designed to be flexibly applied and not diagnosis-specific, aiming to structure communication and generate a personallytailored care plan. This cluster randomised controlled trial (RCT) is part of a programme of research to adapt and test DIALOG+ for patients with chronic depression. Methods: Patients will be eligible for the trial, if they have exhibited symptoms of depression or non-psychotic low mood for at least 2 years, have regular contact with a clinician and have a low subjective quality of life, and moderate depressive symptoms. Clinicians, who routinely see eligible patients, will be recruited from a number of sites across NHS England. Clusters will have between 1 and 6 patients per clinician and will be randomised in a 1:1 ratio to either the intervention (DIALOG+) or active control group (treatment as usual + DIALOG scale). Clinicians in the intervention group are trained and asked to deliver the intervention regularly for 12 months. Active control participants receive treatment as usual and are asked to rate their satisfaction with areas of life and treatment on the DIALOG scale at the end of the clinical session. Approximately 112 clinician clusters will be recruited to reach a total patient sample size of 376. Clinical and social outcomes including costs are assessed at baseline and 3-, 6- and 12-months post randomisation. The primary outcome will be subjective quality of life at 12 months. Discussion: This definitive multi-site, cluster RCT aims to evaluate the clinical- and cost-effectiveness of DIALOG+ for people with chronic depression. If shown to be effective for this patient population it could be used to improve outcomes of mental health care on a larger scale, ensuring that patients with complex and co-morbid diagnoses can benefit.

This paper describes a process developed in order to work collaboratively on a conceptual review of some of the family involvement models that are used in acute mental health treatment. The members of the review team consisted of clinicians, academics and people with lived experience of mental illness and mental health services. This combination of backgrounds had the potential to present many challenges to the dynamics of the group. There were varying levels of research knowledge and experience within the group, as well as a lack of literature describing how to actualize their potential to best effect. Financial resources were minimal, which meant that the number of meetings had to be limited. Most importantly, however, there was the strong potential for a power imbalance within the group during the review process. Senior academics and clinicians were being expected to help to create a research environment in which the patient voice carried as much weight as theirs. In this paper, we discuss how we overcame these challenges and ended up with a process that was coherent, equable and enjoyable.

ObjectivesFamily involvement is strongly recommended in clinical guidelines but suffers from poor implementation. To explore this topic at a conceptual level, a multidisciplinary review team including academics, clinicians and individuals with lived experience undertook a review to explore the theoretical background of family involvement models in acute mental health treatment and how this relates to their delivery.DesignA conceptual review was undertaken, including a systematic search and narrative synthesis. Included family models were mapped onto the most commonly referenced underlying theories: the diathesis–stress model, systems theories and postmodern theories of mental health. Common components of the models were summarised and compared. Lastly, a thematic analysis was undertaken to explore the role of patients and families in the delivery of the approaches.SettingGeneral adult acute mental health treatment.ResultsSix distinct family involvement models were identified: Calgary Family Assessment and Intervention Models, ERIC (Equipe Rapide d’Intervention de Crise), Family Psychoeducation Models, Family Systems Approach, Open Dialogue and the Somerset Model. Findings indicated that despite wide variation in the theoretical models underlying family involvement models, there were many commonalities in their components, such as a focus on communication, language use and joint decision-making. Thematic analysis of the role of patients and families identified several issues for implementation. This included potential harms that could emerge during delivery of the models, such as imposing linear ‘patient–carer’ relationships and the risk of perceived coercion.ConclusionsWe conclude that future staff training may benefit from discussing the chosen family involvement model within the context of other theories of mental health. This may help to clarify the underlying purpose of family involvement and address the diverse needs and world views of patients, families and professionals in acute settings.

Since 1945 at least five United Nations organisations have become substantially involved in international health activities. This has led to considerable confusion among policy makers, scholars, and UN staff over their distinct and appropriate mandates. Interviews with staff and a historical analysis have shown that while formal mandates have been complementary, effective mandates have led to an unclear delineation of activities. The processes of translating formal into effective mandates have been influenced by the decentralised nature of the UN, lack of a master plan for its activities, the considerable growth in the policy agenda, and the shift towards a multisectoral approach to health. The identification of each organisation's comparative advantage, at both the global and country levels, is one way of understanding what each organisation does best and perhaps should be doing. There is a need for improved mechanisms to define effective mandates, taking into account comparative advantages, if the mandates of UN organisations are appropriate to meet future challenges in international health. There has been much recent reflection on and criticism of the World Health Organisation (WHO) and its role in international health.1 What much of this criticism has failed to acknowledge is that the WHO is no longer the only major player in this field and that many of the other players have ceased to regard the WHO as the captain of the team. Much has changed in the UN during the past 50 years. In 1948 the WHO was created as the UN specialised agency in health. Five decades on international health has become crowded with other organisations—notably, the UN Children's Fund, Unicef; the World Bank; the UN Population Fund, UNFPA; and the UN Development Programme, UNDP. All four have active roles in international health but may also at times duplicate activities, compete instead of cooperate, …

epression is a serious medical condition. In contrast to the normal emotional experiences of sadness, loss or passing mood states, clinical depression is persistent and can interfere significantly with an individual’s ability to function. There are three main types of depressive disorder: major depressive disorder, dysthymic disorder, and bipolar disorder (manic-depressive illness). Depression can devastate family relationships, friendships and the ability to function well on a daily basis and, too often, is associated with suicide. Sadly, many people still believe that the emotional symptoms caused by depression are ‘not real’, and that a person should be able to ‘pull themselves together’ and shake off their ‘troubles’. Because of these inaccurate beliefs, people with depression either may not recognise that they have a treatable disorder, or may be discouraged from seeking or staying on treatment due to feelings of shame and stigma. In fact, brain imaging research is revealing that in depression neural circuits responsible for moods, thinking, sleep, appetite and behaviour fail to function properly, and that the regulation of critical neurotransmitters is impaired (Soares & Mann, 1997). Genetics research, including studies of twins, indicates that genes play a role in depression. Vulnerability to depression appears to result from the influence of multiple genes acting in tandem with environmental factors, while other research has shown that stressful life events, particularly loss or bereavement, may trigger major depression in susceptible individuals (Mazure et al, 2000). The hypothalamic-pituitary-adrenal (HPA) axis, the hormonal system that regulates the body’s response to stress, is overactive in many people with depression. Research findings suggest that persistent overactivation of this system may well lay the groundwork for depression (Arborelius et al, 2001). However, while D studies of brain chemistry, mechanisms of action of antidepressant medications, and the cognitive distortions and disturbed interpersonal relationships commonly associated with depression continue to inform the development of new and better treatments, the support and understanding of others are also critical factors on the journey towards remitted depression. Major depression is the world’s number one mental disorder (WHO, 2001). By 2020, it will be the second greatest cause of disability in the developed world. Significantly, nearly twice as many women (12%) as men (7%) are affected by a depressive disorder each year. Within the UK, the extent of the challenge posed by mental illness, and by depression in particular, has at last started to receive the attention, if not quite the resourcing, that the problem requires. We are now aware that one in four of us will at some point suffer from a mental illness. Mental health is a stated Department of Health priority and enhanced training has enabled GPs and psychiatrists to become significantly better able to detect, prescribe for and manage patients with this disabling, painful and sometimes fatal condition. Furthermore, it is now recognised that effective caring for people with depression goes wider than the clinical forum: social, economic and environmental circumstances all have a major impact upon the ‘mental wealth’ of every individual. Because many of the triggers for depression relate to life-shattering events such as unemployment, bereavement or separation, the sufferer can become withdrawn and isolated and thus out of sight becomes, literally, out of mind. Depression Alliance (www.depressionalliance.org) works for the benefit of people suffering from depressive disorders, their families and their carers. It is a member-led organisation with offices in England, Scotland and Wales. Many of those working for Depression Alliance have themselves suffered from depression or have experience as carers and are very

In the head to head debate, Shaw says that to pay patients to take medication would create perverse incentives, but in her discussion she dismisses a particularly complex group of patients, with tuberculosis, despite the public health issues involved.1 2 This is a group of patients for whom payment, or other forms of incentive, are of critical importance, at both the individual and …

If institutional racism is defined as a collective failure that disadvantages people in ethnic minority groups, why is actively treating people for severe illness seen as evidence of such?1 Were this treatment for hypertension, diabetes, or sickle cell anaemia, it would be considered a well targeted intervention. Admission rates and length of stay in mental …