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For people in mental health crisis, acute day units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to crisis resolution teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly compared with those receiving CRT care alone.
We aimed to investigate readmission rates, satisfaction and well-being outcomes for people using ADUs and CRTs.
We conducted a cohort study comparing readmission to acute mental healthcare during a 6-month period for ADU and CRT participants. Secondary outcomes included satisfaction (Client Satisfaction Questionnaire), well-being (Short Warwick–Edinburgh Mental Well-being Scale) and depression (Center for Epidemiologic Studies Depression Scale).
We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312, 42%) across four National Health Service trusts/health regions. There was no statistically significant overall difference in readmissions: 21% of ADU participants and 23% of CRT participants were readmitted over 6 months (adjusted hazard ratio 0.78, 95% CI 0.54–1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4–3.5, P < 0.001) and well-being scores (1.3, 95% CI 0.4–2.1, P = 0.004), and lower depression scores (−1.7, 95% CI −2.7 to −0.8, P < 0.001), than CRT participants.
Patients who accessed ADUs demonstrated better outcomes for satisfaction, well-being and depression, and no significant differences in risk of readmission, compared with those who only used CRTs. Given the positive outcomes for patients, and the fact that ADUs are inconsistently provided in the National Health Service, their value and place in the acute care pathway needs further consideration and research.
Sexual minorities, including those identifying as lesbian, gay, bisexual or queer (LGBQ) are at heightened risk of experiencing mental health problems. Nationally, treatment outcomes within England’s Improving Access to Psychological Therapies (IAPT) services are worse for sexual minority patients than for heterosexuals. An IAPT service in London developed a cognitive behavioural therapy (CBT) group specifically for sexual minority patients to provide a safe, affirmative intervention to learn skills for overcoming depression, anxiety and stress. A qualitative online survey was emailed to all 59 service users who had completed the eight-session intervention, to explore their experiences inductively. Survey data were analysed using qualitative content analysis. Themes were identified in participants’ responses in order to establish which aspects of the group intervention were deemed to be helpful and unhelpful, and to explore suggestions for group improvement. Eighteen people completed the survey (response rate 30.5%). Respondents reported that they found the CBT frame of the group useful, with the LGBQ focus experienced as particularly beneficial, often enhancing engagement with CBT concepts and tools. In addition to generic elements of group therapy that some found difficult, others reported that intragroup diversity, such as generational differences, could lead to a reduced sense of connection. Several suggestions for group improvement were made, including incorporating more diverse perspectives and examples in session content and focusing more on issues relating to intersectionality. These results provide preliminary evidence that a culturally adapted CBT group intervention developed specifically for sexual minorities is acceptable and perceived as offering something unique and helpful.
Key learning aims
(1) To identify the unique experiences and particular mental health disparities that LGBQ people face in life and why a culturally adapted LGBQ CBT group offers both a necessary and unique therapeutic tool to support sexual minorities.
(2) To explore how a culturally adapted CBT group intervention for LGBQ people is experienced in practice, from the service user perspective. In particular, what aspects do LGBQ people find helpful, unhelpful and what might they suggest for future group improvement.
(3) To consider how such CBT groups may be culturally adapted to benefit sexual minorities, including: what actions should be taken in future clinical practice to ensure improvements in the psychological treatment experiences of LGBQ people. Specifically, including the need to incorporate more inclusive and intersectional examples that engage and support recovery from psychological distress.
The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.
To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.
Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.
Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.
Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.
Longitudinal studies of patterns of healthcare contacts in those who die by suicide to identify those at risk are scarce.
To examine type and timing of healthcare contacts in those who die by suicide.
A population-based electronic case–control study of all who died by suicide in Wales, 2001–2017, linking individuals’ electronic healthcare records from general practices, emergency departments and hospitals. We used conditional logistic regression to calculate odds ratios, adjusted for deprivation. We performed a retrospective continuous longitudinal analysis comparing cases’ and controls’ contacts with health services.
We matched 5130 cases with 25 650 controls (5 per case). A representative cohort of 1721 cases (8605 controls) were eligible for the fully linked analysis. In the week before their death, 31.4% of cases and 15.6% of controls contacted health services. The last point of contact was most commonly associated with mental health and most often occurred in general practices. In the month before their death, 16.6 and 13.0% of cases had an emergency department contact and a hospital admission respectively, compared with 5.5 and 4.2% of controls. At any week in the year before their death, cases were more likely to contact healthcare services than controls. Self-harm, mental health and substance misuse contacts were strongly linked with suicide risk, more so when they occurred in emergency departments or as emergency admissions.
Help-seeking occurs in those at risk of suicide and escalates in the weeks before their death. There is an opportunity to identify and intervene through these contacts.
This essay argues that the niche occupied by contemporary Irish poetry in global Anglophone literature is a function of its formal conservatism and resistance to theoretical reflection. Irish poetry offers a moderate and palatable alternative to poetic work that works in a more thoroughgoing fashion through the violence of the present. Its conservative formalism is a hedge against confronting form with the conditions poetry must engage with. Accordingly, much of recent Irish poetry paradoxically furnishes a convenient and consumable commodity form even where it seems to offer an alternative to the economic and ecological spectacle of global transformations. But a number of poets have found formally innovative ways to accommodate both the political violence of the Troubles and the depredations of neoliberalism in Ireland while at the same time drawing on the long history of Irish resistance to such effects of colonialism and capitalism.
The archaeological site of Saruq al-Hadid, Dubai, United Arab Emirates, presents a long sequence of persistent temporary human occupation on the northern edge of the Rub’ al-Khali desert. The site is located in active dune fields, and evidence for human activity is stratified within a deep sequence of natural dune deposits that reflect complex taphonomic processes of deposition, erosion and reworking. This study presents the results of a program of radiocarbon (14C) and thermoluminescence dating on deposits from Saruq al-Hadid, allied with studies of material remains, which are amalgamated with the results of earlier absolute dating studies provide a robust chronology for the use of the site from the Bronze Age to the Islamic period. The results of the dating program allow the various expressions of human activity at the site—ranging from subsistence activities such as hunting and herding, to multi-community ritual activities and large scale metallurgical extraction—to be better situated chronologically, and thus in relation to current debates regarding the development of late prehistoric and early historic societies in southeastern Arabia.
Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.
To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).
Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.
All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.
The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.
Persistence of the embryonic “fifth aortic arch” in postnatal life is a rare, enigmatic – and at times controversial – condition, with variable anatomical forms and physiological consequences. First described in humans over 40 years ago by Van Praagh, the condition was labelled the “great pretender” by Gerlis 25 years later, because of its apparent propensity to mimic anatomically similar structures. Despite many subsequent case reports citing the condition, the true developmental origin of these structures remains unresolved, and has been the subject of debate among embryologists for more than a century. A persistent fifth aortic arch has been defined as an extrapericardial structure, arising from the ascending aorta opposite or proximal to the brachiocephalic artery, and terminating in the dorsal aorta or pulmonary arteries via a persistently patent arterial duct. This description may therefore encompass various anatomical forms, such as a unilateral double-lumen aortic arch, an unrestrictive aortopulmonary shunt, or a critical vascular channel for either the systemic or pulmonary circulation. The physiological properties of these vessels, such as their response to prostaglandins, may also be unpredictable. In this article, we demonstrate a number of cases that fulfil the contemporary definition of “persistent fifth aortic arch” while acknowledging the embryological controversies associated with this term. We also outline the key diagnostic features, particularly with respect to the use of new cross-sectional imaging techniques.
Above all, let Bram not get the idea that I'm moving away from him. The very reverse. The farther I sink down, the more I feel right beside him, feel how much, in spite of the differences, our ventures come together in the unthought and the harrowing. And if there had to be for me a soul-mate, I make bold to say that it would be his soul and no other…. Bram is my great familiar. In work and in the impossibility of working. That's how it will always be.
No consideration of the peculiar version of republicanism that finds its articulation in Jack B. Yeats's painting, and which, as we have seen, Beckett seems to approach in his understanding of that work, can ignore the embeddedness of the notion of the thing in the term ‘republic’ itself. The res publica is the people's thing, la chose du peuple, its matter or affair, what concerns it or that around which it gathers. But in the deontological version of republicanism that Yeats and Beckett seem to have embraced as the resistant residue of a disappointed nationalism, the thing of the republic is no longer a question of representation or expression. Their emphasis falls instead on the recalcitrance of both the human and the thingly to representation, a recalcitrance that Beckett finds set forth in Yeats's insistence on the absolute separation both between humans and between the human and the natural. That insistence would seem to imply, moreover, that what we call the human is itself also a dimension of the thingly once the ‘old relation’ between subject and object that establishes the subject in its relation to its objects has been dissolved. Unimaginable from the perspective of Ireland's post-colonial nationalism, such a dissolution is the very ground of Beckett's aesthetic as he articulates it in the 1930s. It entails at once the abolition of the subject of expression, a term that assumes an a priori interiority that issues in utterances that are consubstantial with it, and the subsumption of the object in whose representation by or for the subject that subject is established in its formal anteriority.
In 1997 Apple computers launched an advertising campaign (in print and on television) that entreated us to ‘Think Different’, and Samuel Beckett was one of Apple's icons. Avoiding Apple's solecism, we might modify the appeal to say that Other Becketts is a call to think differently as well, in this case about Beckett's work, to question, that is, even the questions we ask about it. Other Becketts, then, is a series of monographs focused on alternative, unexplored or under-explored approaches to the work of Samuel Beckett, not a call for novelty per se, but a call to examine afresh those of Beckett's interests that were more arcane than mainstream, interests that might be deemed quirky or strange, and those of his works less thoroughly explored critically and theoretically, the late prose and drama, say, or even the poetry or criticism. Volumes might cover (but are not restricted to) any of the following: unusual illnesses or neurological disorders (the ‘duck foot, goose foot’ of First Love, akathisia or the invented duck's disease or panpygoptosis of Miss Dew in Murphy, proprioception, or its disturbance, in Not I, perhaps, or other unusual neurological lapses among Beckett's creatures, from Watt to the Listener of That Time); mathematical peculiarities (irrational numbers, factorials, Fibonacci numbers or sequences, or non-Euclidian approaches to geometry); linguistic failures (from Nominalism to Mauthner, say); citations of or allusions to contrarian aesthetic philosophers working in a more or less irrationalist tradition (Nietzsche, Bergson or Deleuze, among others), or in general ‘the simple games that time plays with space’. Alternative approaches would be of interest as well, with foci on objects, animals, cognitive or memory issues, and the like.
The work considered as pure creation, and whose function ceases with its genesis, is consigned to nothingness. A single art lover (a wellinformed one) would have saved it. Just one of these gentlemen, faces hollowed by unvalidated enthusiasms, feet flattened by innumerable stations, fingers worn by fifty franc catalogues, who look first from far away, then close up, and who, in particularly thorny cases, assess with their thumbs the depth of the impasto.
Beckett's ironic but affectionate sketch of the art lover, this ‘inoffensive nutcase who runs, as others do to the cinema, to the galleries, the museum, and even into churches’ for the pleasure of viewing art, is as much a self-portrait as a satire. It captures not only the reality of his own life-long love of painting, his genuine connoisseurship, and the independence of his critical views, but also the quality of attention that he was capable of giving to an artwork. It has often been noted that Beckett could stand for hours at a time before a canvas, absorbing its formal qualities, its material relations and rhythms as much as whatever image it conveyed. Painting was in every sense Beckett's ‘thing’: he never seems to have lost his engagement either with individual paintings, or with the aesthetic questions that the contemporary fate of painting as an art form imposed. And his own work in the theatre gives new meaning to the well-worn phrase ‘the painted stage’. Beckett's theatre, for stage and for film or television, this book insists, is not merely like painting or based on paintings, but is its own form of visual art. Visual art in painting and theatre furnished him with the space for an intense mode of thinking that is not confined to formal aesthetic appreciation, formidable as his capacity for that was. His absorption before paintings, his focused concentration on their singular existence as things in and of themselves, became the means to explore a crisis in the modern subject that he early on named ‘the new thing that has happened’ and which would be the focus of his critical writing into the post-war period.
Explores Samuel Beckett's relation to painting and the visual imagination that informs his theatrical work.Beckett was deeply engaged with the visual arts and individual painters, including Jack B. Yeats, Bram van Velde, and Avigdor Arikha. In this monograph, David Lloyd explores what Beckett saw in their paintings. He explains what visual resources Beckett found in these particular painters rather than in the surrealism of Masson or the abstraction of Kandinsky or Mondrian. The analysis of Beckett's visual imagination is based on his criticism and on close analysis of the paintings he viewed. Lloyd shows how Beckett's fascination with these painters illuminates the 'painterly' qualities of his theatre and the philosophical, political and aesthetic implications of Beckett's highly visual dramatic work.Key FeaturesDiscusses Beckett's relationship with three painters crucial to his life-long dialogue with the visual artsThe first book to examine the paintings that Beckett would have known and on which he based his critical remarksAccounts for the increasing visuality of Beckett's theatre in relation to his evolving appreciation of painting and the formal questions posed by that mediumExplores Beckett's anticipation of European phenomenology and psychoanalysis in relation to Heidegger and Lacan