Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups.

To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire.

Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas.

A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased.

Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

Background: The number of suicide-related presentations to emergency departments (EDs) has significantly increased over recent years; thus, making staff often the first point of contact for people in suicidal crisis. Despite this, staff receive minimal psychiatric training and few opportunities for education on the treatment and management of people presenting in suicidal emergencies. Understanding the needs of those who work within EDs is key to maximising the opportunity to reduce suicidal behaviour. Aims: To examine staff perspectives and experiences of working with people presenting to emergency departments in suicidal crisis.

Qualitative study guided by thematic analysis of semi-structured interviews with ED administrative, medical and mental health staff.

Twenty-three staff participated. Three key themes were identified: (1) factors influencing staff decision-making; (2) quality of care for both staff and patients; (3) staff burnout, mental health and well-being. Staff described an overall lack of confidence and training related to asking patients about suicidal thoughts, which resulted in defensive practice and risk adverse decision-making. Quality of care for both patients and staff were discussed in relation to availability of resources, staffing pressures and team collegiality.

Staff felt inadequately equipped to deal with suicide-related presentations. Organisational support is lacking with increased staffing pressures, poor service availability and lack of beds. Negative staff attitudes often reflected an inherent unintentional use of language. Changing ED culture from top-down is imperative to address negative language and behaviours towards suicidal crisis and improve patient pathways and experience. Mandatory and ongoing training is needed to improve staff confidence, knowledge and attitudes.

The recording of suicidal ideation in emergency departments (EDs) is inconsistent and lacks precision, which can impede appropriate referral and follow-up. EDs are often the first point of contact for people experiencing suicide-related distress, but while data are available on attendances for self-harm, no comparable data exist for suicidal crisis.

Data were collected from six EDs across Cheshire and Merseyside (N = 42,096). Data were derived from presenting complaints, chief complaints and diagnosis codes for all suicidal crisis attendances (suicidal ideation, self-harm, suicide attempt) from January 2019 to December 2021.

There was inconsistent coding within and between ED sites for people presenting in suicidal crisis. Attendances for suicidal ideation were often given the chief complaint code of ‘depressive disorder’ (12%). There was a high level of missing data related to the coding of suicide-related presentations (65%). Variation in coding was also reported for individual presentations; for example, 12% of attendances reported to be due to ‘self-inflicted injury’ were given a primary diagnosis code of ‘depressive disorder’ rather than ‘deliberate self-harm’. There was also high variability in the routinely collected data (e.g., demographic information, attendance source and mode, under the influence at time of arrival) both within and between EDs.

Accurate detection and documentation of suicidal crisis is critical to understand future risk and improve services. Research and development in monitoring systems for suicidal crisis should be a priority for health services, and a national data collection tool is urgently needed to maximise accuracy and utility. Better data could be used to inform crisis care policy and to target suicide-prevention resources more effectively.

Carers of individuals presenting with complex behavioural and mental health needs report that service users may not receive the provision of care they require, particularly when presenting following suicide attempts and self-harm. Carers are an integral part of the care system and often feel ignored and marginalised by services; there is a lack of involvement of carers and paucity of their views of support needs to be explored. The aim of the study is to understand carers’ experiences of caring for service users with complex mental health needs who self-harm and/or attempt suicide, and the support received from mental health care services.

Ten carers of service users with complex mental health needs were interviewed about their views on the psychiatric admission, treatment and discharge process for the people they were caring for. Data were gathered during semi-structured, one-to-one interviews remotely over the phone or online platforms. Interviews were audio-recoded and transcribed verbatim. A transcript-based conceptual analysis was conducted to identify and explore emerging themes.

Carers identified both positive and negative aspects of the psychiatric admission and care within community settings. The following key themes emerged from the interviews: lack of control and information from mental health services, the importance of support from staff, or conversely its absence; concerns about service users’ vulnerability, negative staff attitudes and opportunities for involvement; negative experiences of generic psychiatric settings; positive experiences were encountered when there were supportive and caring staff, good information sharing and satisfactory discharge arrangements.

Important areas for service improvements are highlighted. Recommendations included: the need for support; information about suicidal behaviour and advice on managing further incidents at home; more support in coping with regular and escalating self-harming and suicidal behaviours, particularly, severe consequences of staff safeguarding errors and inappropriate discharge, and the importance of supportive and adept staff. These findings identify the need for tailored support for carers regarding the management of self-harm and suicidal behaviours in the community.

Individuals presenting with complex behavioural and mental health needs may not receive the provision of care needed. Those presenting with a more complex clinical presentation may have a history of self-harm and suicide attempts. A common risk factor for preceding suicide is previous self-harm, suicide attempts or discharge from inpatient units. Understanding the descriptive symptom domains for inpatients and those treated in the community and the relationship between them could inform suicide prevention. The aim of this study was to explore the extent of self-harm and suicidal behaviours in individuals with complex mental health needs across inpatient and community settings.

A cohort study design of in-depth written medical notes (n = 80) for people who were known to have complex mental health needs across inpatient and community settings. Data were extracted from medical records onto a coproduced questionnaire. As well as demographic data, information was collated about previous self-harm, suicide planning, suicide attempts, and support seeking regarding suicidal thoughts. The study will include a quantitative in-depth description and inferential analysis of the demographic clinical characteristics of the patient group.

Medical case notes were reviewed for 80 service users with complex mental health needs. Across both groups, approximately three-quarters of participants had previously self-harmed (76%), or planned suicide (n = 73%), and/or attempted suicide (63%). Self-harm (83% vs. 70%) and suicide attempts (72% vs. 65%) were more prevalent in the inpatient group compared to the community group. Social support was received more by community patients than inpatients (70% vs. 50%), even though inpatients were more likely to sough help when experiencing suicidal thoughts compared to people cared for in the community (38% vs. 30%). In both groups, there were often multiple suicide plans and attempts made over their timeline of contact with services.

Self-harm, suicide planning, and suicide attempts were prevalent for people treated across both inpatient and community settings. Self-harm and suicide planning was indicative of a later suicide attempt within both settings. In those experiencing suicidal thoughts, few had sought help, suggesting the importance in staff training to enable then to recognise and identify patterns of self-harming and suicidal behaviours in individuals with complex mental health needs. Social support needs for inpatients should be increased, particularly when they sought help for suicidal thoughts. This may help to reduce length of stays in hospital or future readmissions to hospital; thus, reducing the cost implications for the NHS mental health services.

Little is known about the experiences of individuals presenting with complex mental health needs and the provision of care they receive for suicide and self-harm behaviours. There are limited data describing the support individuals receive from services and, where they do, how this support is provided. Research suggests that those presenting with a more complex clinical presentation may have a history of both suicide attempts and self-harm. The aim of the study is to explore the experiences of individuals with complex mental health needs in respect of their self-harm and suicidal behaviours, and experiences of support received from mental health care services.

A semi-structured interview methodology was used to generate qualitative data. Representative participants with complex mental health needs were recruited from across Cheshire and Wirral Partnership NHS Foundation Trust, UK. Ten participants were interviewed for the study. Interviews were audio-recorded and transcribed verbatim. A transcript-based conceptual analysis was conducted to identify and explore emerging themes.

The following three themes emerged from the service user interviews: (i) Service users discussed suicide attempts following inappropriate discharge; Service users spoke about feeling unsupported and not listened to by care staff, particularly as inpatients; and (ii) Service users expressed a necessity for staff training to improve understanding of self-harm and suicide attempts, having experienced negative consequences of staff handling when they may have self-harmed.

This study highlighted the following recommendations for future suicide prevention for mental health services treating service users with complex mental health needs: increasing staff awareness of suicide or self-harm related issues; improving training and risk assessment skills; providing appropriate support for service users following discharge from inpatient settings; improving liaison and collaboration between services to provide better service user outcomes; and increasing awareness in listening to service users’ distress about suicidal or self-harm thoughts for each individual's situational context.

Mental health services for adults have been developed to provide community-based interventions. There is a recognized unmet need in some of the most complex patients that may not be adequately met by existing mental health services provision. Research is warranted to consider the best model of service delivery for this group of service users. The aims of this research were to examine the profile and history of service users defined as having complex needs as well as their service use and associated costs in the Cheshire and Wirral Partnership NHS Foundation Trust (CWP).

A diverse group of stakeholders were invited to provide feedback on the content and design of the proforma for data collection from the medical records of service users. The rationale of the data collection was described to ensure relevant patient-level cost information was collected to identify and quantify the relevant resources consumed, to inform the evaluation of direct medical costs, direct non-medical costs, and indirect costs for each patient. The proforma was designed to also permit comparisons of clinical and service use outcomes for evaluation of patient health and non-health outcomes associated with alternative care pathways.

Stakeholder feedback comprised representatives from the CWP, patients, commissioners, the Local Authority, and housing. Relevant data for extraction from patient medical records were identified and a proforma was developed. The following items were identified for inclusion: baseline demographic data, service user data (family background, contact with the criminal justice system, social history), and clinical data (diagnosis, treatment, hospital visits, and other health service use).

A proforma was developed with diverse stakeholder involvement to inform data collection on the resource use and cost impact associated with alternative care pathways in the National Health Service and other sectors of the economy. Based on the proforma developed and data extracted, an exploration of patient health and non-health outcomes associated with alternative care pathways will be conducted to inform service evaluation and to promote patient centric care.

Co-production recognises that people who use social care services (and their families) and third sector organisations within community settings have knowledge and experience that can be used to help make services better for services users and those who care for them. This study shares the coproduction that took place in the design of a mixed methods study that aims to understand: the profile and history of service users currently defined as having complex needs; the decision-making processes by clinicians that lead to these individuals entering this complex group; service users and carers experience of service use; and, the associated costs. This study involves a comprehensive evaluation that aims to inform an evidence-based service delivery model for mental health service users with complex needs.

A study stakeholder group, including clinicians, academics, service users, housing associations, health economists, and statisticians was formed from the outset to inform the mixed methods design, combining quantitative (in-depth analysis of patient records and economic evaluation) and qualitative (written medical notes and in-depth interviews with service users, carers, and clinicians) methods. The study included five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of direct medical costs, direct non-medical costs, and indirect costs for each patient; (3) semi-structured interviews about patients and carers experiences; (4) data from components 1-3 was used to co-produce vignettes jointly with the stakeholders group; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group by using the vignettes as example case studies.

Coproduction took place at each stage of the study, including the design, development of data collection tools, data analysis and formation of the vignettes required for stage five. The results demonstrated how co-production and multiagency working have been evident throughout the process of designing the study, the continuous engagement throughout the analysis, dissemination and implementation of the findings.

The findings support the application of the core principles of co-production in the design, set-up and implementation of research within an NHS Trust as demonstrable by the acceptability and collaborative working within the study. The study's key outcomes were to: examine the resource use and cost impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how decisions are made in their treatment to inform how services are delivered in the future and made more person-centred and consistent.