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Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.
This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.
The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3–5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).
In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI –1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.
Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.
Patients often have very different ideas from clinicians about what they want treatments to achieve. Their views on what outcomes are important are not always reflected in trials.
To elicit the views of people who self-harm on the most commonly used outcome measures and to identify the outcomes that matter to them.
We conducted in-depth interviews with 18 people with histories of self-harm, recruited from hospital and community settings. We conducted thematic analysis using a framework approach and used visual mapping to arrive at our final analysis and interpretation.
Participants' accounts contained a number of challenges to the validity and meaningfulness of current trial outcome measures. Five broad issues emerged: (a) relationship between frequency and severity of self-harm; (b) behavioural substitution; (b) self-management skills; (d) the role of self-harm as survival tool and affect regulator, and (e) strategic self-presentation. We show how these affect the visibility and measurability of commonly used outcomes. The outcomes that mattered to participants focused on positive achievements in three domains: (a) general functioning and activities of everyday living; (b) social participation, and (c) engagement with services. Participants conceptualised these as both measures and means of sustained improvement.
Our findings suggest that current self-harm trial science rests on flawed assumptions about the relationship between mental states and behaviours and about our ability to measure both. Greater understanding of the outcomes that matter to people who self-harm is needed to inform both intervention development and trial design.
Presentation at an accident and emergency (A&E) department is a key
opportunity to engage with a young person who self-harms. The needs of
this vulnerable group and their fears about presenting to healthcare
services, including A&E, are poorly understood.
To examine young people's perceptions of A&E treatment following
self-harm and their views on what constitutes a positive clinical
Secondary analysis of qualitative data from an experimental online
discussion forum. Threads selected for secondary analysis represent the
views of 31 young people aged 16–25 with experience of self-harm.
Participants reported avoiding A&E whenever possible, based on their
own and others' previous poor experiences. When forced to seek emergency
care, they did so with feelings of shame and unworthiness. These feelings
were reinforced when they received what they perceived as punitive
treatment from A&E staff, perpetuating a cycle of shame, avoidance
and further self-harm. Positive encounters were those in which they
received ‘treatment as usual’, i.e. non-discriminatory care, delivered
with kindness, which had the potential to challenge negative
self-evaluation and break the cycle.
The clinical needs of young people who self-harm continue to demand
urgent attention. Further hypothesis testing and trials of different
models of care delivery for this vulnerable group are warranted.
To explore what young people who self-harm think about online self-harm discussion forums. SharpTalk was set up to facilitate shared learning between health professionals and young people who self-harm. We extracted themes and illustrative statements from the online discussion and asked participants to rate statements.
Of 77 young people who participated in the forum, 47 completed the questionnaire. They said they learned more about mental health issues from online discussion forums than from information sites, found it easier to talk about self-harm to strangers than to family or friends, and preferred to talk online than face-to-face or on the telephone. They valued the anonymity the forums provided and reported feeling more able to disclose and less likely to be judged online than in ‘real life’.
Mental health professionals should be aware of the value of anonymous online discussion forums for some young people who self-harm, so that they can talk about them and assess their use with their patients.