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  • System-level barriers to personal recovery in mental health: qualitative analysis of co-productive narrative dialogues between users and professionals

  • Miharu Nakanishi, George Kurokawa, Junko Niimura, Atsushi Nishida, Geoff Shepherd, Syudo Yamasaki
  • Journal:
    BJPsych Open / Volume 7 / Issue 1 / January 2021
    Published online by Cambridge University Press:
    07 January 2021, e25
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  • Background

    No co-productive narrative synthesis of system-level facilitators and barriers to personal recovery in mental illness has been undertaken.

    Aims

    To clarify system-level facilitators and barriers to personal recovery of people with mental illness.

    Method

    Qualitative study guided by thematic analysis. Data were collected through one focus group, which involved seven service users and three professionals. This group had 11 meetings, each lasting 2 h at a local research institute, between July 2016 to January 2018.

    Results

    The analysis yielded three themes: barriers inhibiting positive interaction within personal relationship networks, roots of barriers from mental health systems and the social cultural context, and possible solutions to address the roots. Barriers were acknowledged as those related to sense of safety, locus of control within oneself and reunion with self. The roots of barriers were recognised within mental health services, including system without trauma sensitivity, lack of advocacy support and limited access to psychosocial approaches. Roots from social cultural context were also found. There were no narratives relating to facilitators. A possible solution was to address the roots from systems. Social cultural change was called for that makes personalised goals most valued, with an inclusive design that overcomes stigma, to achieve an open and accepting community.

    Conclusions

    The analysis yielded system-level barriers specific to each recovery process. Roots of barriers that need transformation to facilitate personal recovery were identified within mental health services. Social interventions should be further explored to translate the suggested social cultural changes into action.

  • OP88 Digital Approaches For Randomized Controlled Trial Recruitment Or Retention: A Systematic Map

  • Geoff Frampton, Jonathan Shepherd, Karen Pickett, Gareth Griffiths, Jeremy Wyatt
  • Journal:
    International Journal of Technology Assessment in Health Care / Volume 35 / Issue S1 / 2019
    Published online by Cambridge University Press:
    31 December 2019, pp. 22-23
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  • Introduction

    Recruitment and retention of participants in randomized controlled trials (RCTs) is challenging, and is why many RCTs fail or are not completed on time. Digital approaches such as social media, data mining, email or text messaging could improve recruitment and/or retention, but how well they match these purposes is unclear. We used systematic methods to map the digital approaches that have been investigated during the past 10 years.

    Methods

    We searched Medline, Embase, other databases and relevant web sites in July 2018 to identify comparative studies of digital approaches for recruiting and/or retaining participants in clinical or health RCTs. Two reviewers screened references against protocol-specified eligibility criteria. Studies included were coded by one reviewer (with 20 percent checked by a second reviewer) using pre-defined keywords to describe characteristics of the studies, populations and digital approaches evaluated.

    Results

    We identified 9,133 potentially relevant references, of which 100, reporting 101 unique studies, met the criteria for inclusion in the map. Among these, 95 percent of studies investigated recruitment but only 11 percent investigated retention. Study areas included health promotion and public health (36 percent), cancer (17 percent), circulatory system disorders (13 percent) and mental health (10 percent). Most study designs were observational (89 percent). The most frequent digital approaches for recruitment were internet sites (53 percent of recruitment studies), social media (42 percent), television or radio (31 percent) and/or email (31 percent). For retention these were email (63 percent of retention studies) or text messaging (38 percent). Time and costs of recruitment were reported in 17 percent and 30 percent of recruitment studies respectively, whilst costs were reported in 19 percent of retention studies.

    Conclusions

    A wide range of digital approaches has been studied, in many combinations. Evidence gaps include lack of experimental studies; studies on retention; and studies for specific populations (e.g. children or older people) and outcomes (e.g. user satisfaction). More robust experimental studies, perhaps conducted as studies-within-a-trial (SWAT), are needed to address knowledge gaps and ensure that estimates of digital tool effectiveness and efficiency are reliable.

  • Predictors of moving on from mental health supported accommodation in England: national cohort study

  • Helen Killaspy, Stefan Priebe, Peter McPherson, Zohra Zenasni, Lauren Greenberg, Paul McCrone, Sarah Dowling, Isobel Harrison, Joanna Krotofil, Christian Dalton-Locke, Rose McGranahan, Maurice Arbuthnott, Sarah Curtis, Gerard Leavey, Geoff Shepherd, Sandra Eldridge, Michael King
  • Journal:
    The British Journal of Psychiatry / Volume 216 / Issue 6 / June 2020
    Published online by Cambridge University Press:
    03 May 2019, pp. 331-337
    Print publication:
    June 2020
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  • Background

    Around 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness.

    Aims

    A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation.

    Method

    We used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics.

    Results

    Overall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92–21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01–7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice.

    Conclusions

    Most people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.

  • PP021 Peer Review Innovations For Grant Applications: Efficient And Effective?

  • Geoff Frampton, Jonathan Shepherd, Karen Pickett, Jeremy Wyatt
  • Journal:
    International Journal of Technology Assessment in Health Care / Volume 33 / Issue S1 / 2017
    Published online by Cambridge University Press:
    12 January 2018, pp. 78-79
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  • INTRODUCTION:

    Peer review of grant applications is employed routinely by health research funding bodies to determine which research proposals should be funded. Peer review faces a number of criticisms, however, especially that it is time consuming, financially expensive, and may not select the best proposals. Various modifications to peer review have been examined in research studies but these have not been systematically reviewed to guide Health Technology Assessment (HTA) funding agencies.

    METHODS:

    We developed a systematic map based on a logic model to summarize the characteristics of empirical studies that have investigated peer review of health research grant applications. Consultation with stakeholders from a major health research funder (the United Kingdom National Institute for Health Research, NIHR) helped to identify topic areas within the map of particular interest. Innovations that could improve the efficiency and/or effectiveness of peer review were agreed as being a priority for more detailed analysis. Studies of these innovations were identified using pre-specified eligibility criteria and were subjected to a full systematic review.

    RESULTS:

    The systematic map includes eighty-one studies, most published since 2005, indicating an increasing area of investigation. Studies were mostly observational and retrospective in design, and a large proportion have been conducted in the United States, with many conducted by the National Institutes of Health. An example of an innovation is video training to improve reviewer reliability. Although research councils in the United Kingdom have conducted several relevant studies, these have mainly examined existing practices rather than testing peer review innovations. Full results of the systematic review will be provided in the presentation, and we will assess which innovations could improve the efficiency and/or effectiveness of peer review for selecting health research proposals.

    CONCLUSIONS:

    Despite considerable interest in, and criticism of, peer review for helping to select health research proposals, there have been few detailed systematic examinations of the primary research evidence in this area. Our evidence synthesis provides the most up-to-date overview of evidence in this important developing area, with recommendations for health research funders in their decision making.

  • 13 - Social inclusion: research and evidence-based practice

  • from Part 3 - Working towards inclusive psychiatry
  • Edited by Jed Boardman, Alan Currie, Helen Killaspy, Gillian Mezey
  • Book:
    Social Inclusion and Mental Health
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 279-294

  • Summary

    As we have seen in earlier chapters, social inclusion is a complex concept which overlaps with several other important ideas in social and community psychiatry and which has potentially wide applicability to a range of individuals and groups.

    In this chapter we will discuss some of the key methodological issues and research outcomes relating to research in social exclusion and mental ill health. Throughout, we will be concerned with research that addresses both social exclusion and mental illness, not with either alone, although they are clearly related. Given the breadth of this field, our review will be selective, aiming to give a general overview of the literature, rather than a comprehensive account.

    Measurement

    Conceptual and methodological issues

    Measures of social inclusion fall into two broad categories, individual level and societal level (Berman & Phillips, 2000):

    1. 1 individual-level measures reflect the situation and life experience of people belonging to socially excluded groups (in this case people with mental health problems); they are usually of more interest to mental health practitioners and clinically-oriented researchers

    2. 2 societal-level measures, also sometimes referred to as a ‘social indicators’ approach, rely on existing data sources that characterise levels of participation in larger community samples – examples of this are employment rates as assessed in the annual Labour Force Survey (Department for Work and Pensions, 2007) and the number of rough sleepers as calculated by local authorities (Palmer et al, 2007); this approach tends to be of more interest to planners, politicians and social policy-makers.

    Notwithstanding the importance of reliability, any measurement tool for social inclusion must also have validity. Thus, it must ‘converge’ with other instruments measuring similar concepts, such as poverty, citizenship, social capital, ‘quality of life’. However, it must also ‘diverge’ (discriminate) between social inclusion and these related concepts. For example, social inclusion combines aspects of poverty (e.g. income, welfare benefits, exclusion from the labour market) but also elements of social participation. Similarly, it includes aspects of social capital (e.g. membership of social networks, community groups and civic participation) but adds in poverty and stigma and discrimination. It also overlaps with quality of life measures in terms of both objective and subjective indicators. Any comprehensive measure of social inclusion must therefore meet these challenges to content and discriminant validity.

  • 19 - Housing: a place to live

  • from Part 3 - Key elements of a rehabilitation service
    • By Helen Killaspy, Professor of Rehabilitation Psychiatry, Mental Health Sciences Unit, University College London, Stefan Priebe, Professor of Social and Community Psychiatry, Newham Centre for Mental Health, London, Geoff Shepherd, Professor of Psychology, Senior Policy Advisor, Centre for Mental Health, London
  • Edited by Frank Holloway, Sridevi Kalidindi, Helen Killaspy, Glenn Roberts
  • Book:
    Enabling Recovery
    Published online:
    02 January 2018
    Print publication:
    01 July 2015, pp 295-307

  • Summary

    Introduction

    This chapter describes the history, development and evidence for supported accommodation for people with mental health problems. Clearly, people with mental health problems who do not reside in supported accommodation also need somewhere to live and support to remain as well as possible and maintain their home successfully: in the UK most live alone, although many do live with family. People living in supported accommodation will require the interventions described in Part 2 of this book (‘Treatment approaches’), delivered by the community-based services described in Chapter 18, ‘Community-based rehabilitation and recovery’; these are not reiterated here.

    Specialist supported accommodation for people with mental health problems includes nursing and residential care homes, group homes, hostels, blocks of individual or shared tenancies with staff on site, and independent tenancies with ‘floating’ or outreach support from staff. In 2006 it was estimated that around 12 500 people with mental health problems in England were in a nursing or residential care home (National Statistics, 2006), although a recent ‘freedom of information’ enquiry to the organisations commissioning these services – local authorities and National Health Service (NHS) primary care trusts – puts the figure much higher, at around 30 000 (Killaspy & Meier, 2010). This discrepancy could be due to changes in the registration processes for these kinds of facilities, which have led to an increase in the number of homes formally registered, rather than an increase in the actual number of people residing in them, although there has also been greater use of nursing and residential care for people with longer-term mental health problems in the UK in recent years owing to disinvestment in local rehabilitation services (on the ‘virtual asylum’, see Chapter 17, ‘Rehabilitation in hospital settings’). In 2006, around 160 000 people in England were receiving floating outreach services, of whom around 15% (24 000) were classified as receiving a specialist mental health floating outreach service (Department of Communities and Local Government, 2006).

  • Vocational rehabilitation in early psychosis: cluster randomised trial

  • Tom Craig, Geoff Shepherd, Miles Rinaldi, Jo Smith, Sarah Carr, Fay Preston, Swaran Singh
  • Journal:
    The British Journal of Psychiatry / Volume 205 / Issue 2 / August 2014
    Published online by Cambridge University Press:
    02 January 2018, pp. 145-150
    Print publication:
    August 2014
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  • Background

    Individual placement and support (IPS) is effective in helping patients return to work but is poorly implemented because of clinical ambivalence and fears of relapse.

    Aims

    To assess whether a motivational intervention (motivational interviewing) directed at clinical staff to address ambivalence about employment improved patients' occupational outcomes.

    Method

    Two of four early intervention teams that already provided IPS were randomised to receive motivational interviewing training for clinicians, focused on attitudinal barriers to employment. The trial was registered with the International Standard Randomised Controlled Trial Register (ISRCTN71943786).

    Results

    Of 300 eligible participants, 159 consented to the research. Occupational outcomes were obtained for 134 patients (85%) at 12-month follow-up. More patients in the intervention teams than in the IPS-only teams achieved employment by 12 months (29/68 v. 12/66). A random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants' gender, ethnicity, educational and employment history and clinical status scores, confirmed superiority of the intervention (odds ratio = 4.3, 95% CI 1.5–16.6).

    Conclusions

    Employment outcomes were enhanced by addressing clinicians' ambivalence about their patients returning to work.

  • AN ECONOMIC MODEL OF SCHOOL-BASED BEHAVIORAL INTERVENTIONS TO PREVENT SEXUALLY TRANSMITTED INFECTIONS

  • Keith Cooper, Jonathan Shepherd, Jo Picot, Jeremy Jones, Josephine Kavanagh, Angela Harden, Elaine Barnett-Page, Andrew Clegg, Debbie Hartwell, Geoff Frampton, Alison Price
  • Journal:
    International Journal of Technology Assessment in Health Care / Volume 28 / Issue 4 / October 2012
    Published online by Cambridge University Press:
    21 September 2012, pp. 407-414
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  • Objectives: Reducing sexually transmitted infections (STI) and teenage pregnancy through effective health education is a high priority for health policy. Behavioral interventions which teach skills to practice safer sex may reduce the incidence of STIs. We evaluated the cost-effectiveness of school-based behavioral interventions in young people.

    Methods: We developed an economic model to estimate the total number of STI cases averted, consequent gain in health related quality of life (HRQoL) and savings in medical costs, based on changes in sexual behavior. The parameters for the model were derived from a systematic literature search on the intervention effectiveness, epidemiology of STIs, sexual behavior and lifestyles, HRQoL and health service costs.

    Results: The costs of providing teacher-led and peer-led behavioral interventions were €5.16 and €18 per pupil, respectively. For a cohort of 1000 boys and 1000 girls aged 15 years, the model estimated that the behavioral interventions would avert two STI cases and save 0.35 Quality Adjusted Life Years (QALYs). Compared to standard education, the incremental cost-effectiveness of the teacher-led and peer-led interventions was €24,268 and €96,938 per QALY gained, respectively.

    Conclusions: School-based behavioral interventions which provide information and teach young people sexual health skills can bring about improvements in knowledge and increased self-efficacy, though these may be limited in terms of impact on sexual behavior. There was uncertainty around the results due to the limited effect of the intervention on behavioral outcomes and paucity of data for other input parameters.

  • Supported accommodation for people with severe mental illness: an update

  • Rob Macpherson, Geoff Shepherd, Praveen Thyarappa
  • Journal:
    Advances in Psychiatric Treatment / Volume 18 / Issue 5 / September 2012
    Published online by Cambridge University Press:
    02 January 2018, pp. 381-391
    Print publication:
    September 2012
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  • Appropriate housing and support are essential elements in the care of many people with mental health problems, and housing has a major impact on the quality of their lives. In the post-deinstitutionalised services of most high-income countries, a complex range of supported accommodation is available, mostly in the private (for-profit and not-for-profit) sector. We describe the different forms of accommodation and consider recent trends in policy and practice and the evidence base in this area. We also discuss quality issues and the potential impact of the recovery movement.

  • Implementing recovery in mental health services

  • Jed Boardman, Geoff Shepherd
  • Journal:
    International Psychiatry / Volume 9 / Issue 1 / February 2012
    Published online by Cambridge University Press:
    02 January 2018, pp. 6-8
    Print publication:
    February 2012
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  • The ideas of ‘recovery’ arise from the experiences of people with mental health problems. The recovery approach emerged in the North American civil rights and consumer and survivor movements from the 1970s onwards. It is concerned with social justice, individual rights, citizenship, equality, freedom from prejudice and discrimination. In this paper we discuss a project in England that has examined how mental health services may be transformed to be more supportive of recovery and the implications that this has for professional practice.

  • System failure? The problems of reductions in long-stay beds in the UK1

  • Geoff Shepherd
  • Journal:
    Epidemiologia e Psichiatria Sociale / Volume 7 / Issue 2 / August 1998
    Published online by Cambridge University Press:
    11 October 2011, pp. 127-134

  • Objective — To review the relevant literature on the effects of reductions in long stay beds on mental health services in the UK. Method — A selective literature review, with particular reference to research conducted by the author and colleagues at The Sainsbury Centre for Mental Health.Results — The evidence suggests that the effects of long stay bed reductions should be examined with regard to 'old' and 'new' long stay patients separately. While the 'old' long stay who have been most directly effected by these changes have generally fared well; the 'new' long stay have not. They are currently accumulating in acute inpatient units, often on general hospital sites, or are rotating in the 'revolving door' of acute inpatient care and inadequate community supports. Although it is clear that there is a shortage of acute beds especially in inner city areas many of the these beds are currently occupied by patients who would be better (and less expensively) cared for in community alternatives if these were available. The evidence suggests that it is possible to im-prove outcomes for this 'new' long stay group if specific kinds of housing, work and assertive community teams are provided. Conclusions — It is concluded that the effects of long stay bed reductions should be considered in a 'systems perspective'. Effective community services can be established, but in order to achieve effective substitution of one kind of service for another, there must be a well co-ordinated, clearly targeted, and technically efficient system. At the present time such services are rare. However, simply focusing on one element (e.g. beds) is unlikely to produce cost effective and efficient solutions.

  • 13 - Social inclusion: research and evidence-based practice

  • from Part 3 - Working towards inclusive psychiatry
  • Edited by Jed Boardman, Alan Currie, Helen Killaspy, Gillian Mezey
  • Book:
    Social Inclusion and Mental Health
    Published online:
    01 January 2018
    Print publication:
    01 June 2010, pp 279-294

  • Summary

    As we have seen in earlier chapters, social inclusion is a complex concept which overlaps with several other important ideas in social and community psychiatry and which has potentially wide applicability to a range of individuals and groups.

    In this chapter we will discuss some of the key methodological issues and research outcomes relating to research in social exclusion and mental ill health. Throughout, we will be concerned with research that addresses both social exclusion and mental illness, not with either alone, although they are clearly related. Given the breadth of this field, our review will be selective, aiming to give a general overview of the literature, rather than a comprehensive account.

    Measurement

    Conceptual and methodological issues

    Measures of social inclusion fall into two broad categories, individual level and societal level (Berman & Phillips, 2000):

  • individual-level measures reflect the situation and life experience of people belonging to socially excluded groups (in this case people with mental health problems); they are usually of more interest to mental health practitioners and clinically-oriented researchers

  • societal-level measures, also sometimes referred to as a ‘social indicators’ approach, rely on existing data sources that characterise levels of participation in larger community samples – examples of this are employment rates as assessed in the annual Labour Force Survey (Department for Work and Pensions, 2007) and the number of rough sleepers as calculated by local authorities (Palmer et al, 2007); this approach tends to be of more interest to planners, politicians and social policy-makers.

    • Notwithstanding the importance of reliability, any measurement tool for social inclusion must also have validity. Thus, it must ‘converge’ with other instruments measuring similar concepts, such as poverty, citizenship, social capital, ‘quality of life’. However, it must also ‘diverge’ (discriminate) between social inclusion and these related concepts. For example, social inclusion combines aspects of poverty (e.g. income, welfare benefits, exclusion from the labour market) but also elements of social participation. Similarly, it includes aspects of social capital (e.g. membership of social networks, community groups and civic participation) but adds in poverty and stigma and discrimination. It also overlaps with quality of life measures in terms of both objective and subjective indicators. Any comprehensive measure of social inclusion must therefore meet these challenges to content and discriminant validity.

  • Organization and interaction in psychiatric day centres

  • Geoff Shepherd, Anne Richardson
  • Journal:
    Psychological Medicine / Volume 9 / Issue 3 / August 1979
    Published online by Cambridge University Press:
    09 July 2009, pp. 573-579

  • One of the major problems in the care of chronic patients is the design of suitable long-term environments. Following from the work of Tizard and his colleagues, a study is described which investigated the aspects of the organization, management practices and social interactions in 4 local authority day centres for the care of chronic patients in the community. It was found that these centres differed markedly in terms of their organization and management practices and that these differences were correlated with the nature and quality of staff-client (although not staff–staff) interactions. Client-oriented management attitudes were correlated with a more personal approach to clients' problems and a warmer quality of interaction. These differences did not seem attributable to different kinds of clients being involved in each centre. The results are discussed in terms of the possible causal mechanisms involved and their implications for designing systems of long-term care.

  • In-patient and residential alternatives to standard acute psychiatric wards in England

  • Sonia Johnson, Helen Gilburt, Brynmor Lloyd-Evans, David P. J. Osborn, Jed Boardman, Morven Leese, Geoff Shepherd, Graham Thornicroft, Mike Slade
  • Journal:
    The British Journal of Psychiatry / Volume 194 / Issue 5 / May 2009
    Published online by Cambridge University Press:
    02 January 2018, pp. 456-463
    Print publication:
    May 2009
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  • Background

    Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years.

    Aims

    Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations.

    Method

    National cross-sectional survey of alternatives to standard acute in-patient care.

    Results

    We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions.

    Conclusions

    Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

  • Supported accommodation for people with severe mental illness: a review

  • Rob Macpherson, Geoff Shepherd, Tom Edwards
  • Journal:
    Advances in Psychiatric Treatment / Volume 10 / Issue 3 / May 2004
    Published online by Cambridge University Press:
    02 January 2018, pp. 180-188
    Print publication:
    May 2004
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  • The authors describe the main forms of supported accommodation available to people with mental health problems in the UK. They address the questions of who needs supported accommodation and how people may be selected for the differing types of unit. Historical trends and policy in this area are reviewed and the general research evidence and evidence of cost-effectiveness are considered. A ‘total system’ approach to assessing accommodation need in a locality is advocated. The authors also consider key quality issues that should be addressed for supported accommodation to be effective.

  • Acute wards: problems and solutions: Implementing real change in acute in-patient care – more than just bringing in the builders ….

  • Susannah Rix, Geoff Shepherd
  • Journal:
    Psychiatric Bulletin / Volume 27 / Issue 3 / March 2003
    Published online by Cambridge University Press:
    02 January 2018, pp. 108-111
    Print publication:
    March 2003
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  • Aims and Method

    To develop an evidence-based approach that supports the improvement of front-line delivery of adult acute in-patient services. Key factors of effective organisational change were identified from the literature. These were adopted as part of an ‘evidence-based service development’ programme. This approach was used by the Health Advisory Service in a project with an NHS Trust in south east England.

    Results

    Significant progress was made in improving the quality of local acute in-patient services.

    Clinical Implications

    Further development and evaluation of this approach should be undertaken, since it seems to offer significant opportunities to deliver real improvements in the quality of services.

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