There is evidence that children and young people (CYP) of Black ethnicity are more likely to experience involuntary hospital admission. This is not explained by clinical and sociodemographic factors. One possible explanation are differences in pathways into, and/or use of mental health services (MHS). This study investigates the associations between ethnicity, pathways into MHS, MHS use and involuntary hospitalisation in CYP.

Using data from the Clinical Record Interactive Search (CRIS) system for (South London and the Maudsley) SLaM services we identified 652 CYP under 18 years admitted to inpatient units between 2008 and 2021 living within the SLaM catchment; 458 (70.2%) were admitted informally and 194 (29.7%) were detained. We conducted univariable logistic regression to investigate the association between pathways into MHS (referral source, S.136 presentation), MHS use (time known to services, recent appointment prior to admission, and presence of a care plan), clinical factors (diagnosis, severity, risk) and social factors (gender, age, ethnicity, deprivation) with the outcome i.e. involuntary admission. We then conducted multivariable logistic regression to investigate the association between the clinical and social factors and involuntary admission.

In multivariable analyses we found evidence that adverse pathways into MHS such as S.136 presentation (OR 6.25, 95%CI 2.06-19.01, p = 0.001), and referrals from social services (OR 4.92, 95%CI 1.49-16.19, p = 0.009) and police/legal services (OR 4.22, 95%CI 1.03-17.31, p = 0.045) were associated with involuntary hospitalisation. There was no evidence that the duration of contact with MHS, having had an appointment in the 28 days prior to admission or a care plan in the 12 months prior to admission were associated with involuntary hospitalisation after adjusting for other factors. There was evidence that being of Black ethnicity (OR 2.04, 95%CI 1.19-3.50, p = 0.010), older age (13–15 years: OR 4.46, 95%CI 1.57-12.72, p = 0.005; age 16–17 years: OR 8.67, 95%CI 3.08-24.41, p < 0.001) and having a diagnosis of a psychotic disorder (OR 4.21, 95%CI 2.21-8.02, p < 0.001) were associated with involuntary admission after accounting for pathways into and use of MHS.

In this cohort of child and adolescent inpatients living in South East London, we found that CYP who experience adverse pathways into MHS are more likely to experience involuntary hospitalisation. Prior contact with MHS did not appear to influence involuntary admission. We found that Black CYP remained more than twice as likely to be admitted involuntarily after accounting for MHS use and pathways into MHS as well as social and clinical factors.

Autistic people have a high likelihood of developing mental health difficulties but a low chance of receiving effective mental healthcare. Therefore, there is a need to identify and examine strategies to improve mental healthcare for autistic people.

To identify strategies that have been implemented to improve access, experiences of care and mental health outcomes for autistic adults, and to examine evidence on their acceptability, feasibility and effectiveness.

A co-produced systematic review was conducted. MEDLINE, PsycINFO, CINHAL, medRxiv and PsyArXiv were searched. We included all study designs reporting acceptability or feasibility outcomes and empirical quantitative study designs reporting effectiveness outcomes. Data were synthesised using a narrative approach.

A total of 30 articles were identified. These included 16 studies of adapted mental health interventions, eight studies of service improvements and six studies of bespoke mental health interventions developed for autistic people. There was no conclusive evidence on effectiveness. However, most bespoke and adapted approaches appeared to be feasible and acceptable. Identified adaptations appeared to be acceptable and feasible, including increasing knowledge and detection of autism, providing environmental adjustments and communication accommodations, accommodating individual differences and modifying the structure and content of interventions.

Many identified strategies are feasible and acceptable, and can be readily implemented in services with the potential to make mental healthcare more suitable for autistic people, but important research gaps remain. Future research should address these and investigate a co-produced package of service improvement measures.

Little is known about the use of the Mental Health Act (MHA) in children and young people (CYP). There is some evidence that having a diagnosis of psychosis or substance misuse disorder, having an intellectual disability, being older and being of black ethnicity are associated with involuntary admission. However, the existing literature is limited and relies on retrospective case note review or surveys based on a small number of sites over short periods of time. We investigated the social and clinical factors associated with MHA use in CYP using electronic health records. We hypothesised that older adolescence, psychosis, more severe illness, the presence of risk to others and Black ethnicity would be associated with involuntary admission under the MHA.

Using data from the Clinical Record Interactive Search (CRIS) system for South London and the Maudsley (SLaM) services we identified 2165 CYP under 18 years, with a first admission to inpatient units between 2007 and 2021 with complete data on variables of interest; 1638 (75.7%) were voluntary patients for the duration of the admission and 527 (25.3%) had been detained under a section 2 or 3 of the MHA during the admission. We conducted univariable logistic regression to investigate the association between clinical factors (diagnosis, severity of illness, risk) and social factors (gender, age, ethnicity, deprivation) with the outcome i.e. MHA admission. We then conducted multivariable logistic regression to investigate the association between the clinical and social factors and involuntary admission.

In multivariable analyses we found evidence that a diagnosis of psychosis (OR 2.63, 95% CI 1.83–3.76, p < 0.001), being older (age 13–15 years: OR 5.88, 95% CI 3.46–10.03, p < 0.001; age 16–17 years: OR 6.72, 95% CI 3.97–11.41, p < 0.001), having a developmental disorder (OR 1.60, 95% CI 1.04–2.47, p = 0.033) and being of Black ethnicity (OR 2.14, 95% CI 1.60–2.89, p < 0.001) were associated with involuntary admission after accounting for other factors. Being less impaired (i.e. a higher CGAS score) was associated with a lower odds of involuntary admission (moderate impairment: OR 0.56, 95% CI 0.42–0.74, p < 0.001; lowest impairment: OR 0.41, 95% CI 0.30–0.54, p < 0.001).

In this large cohort of child and adolescent inpatients from South East London, we found that CYP of Black ethnicity are more likely than those from White groups to have an involuntary than voluntary psychiatric hospitalisation, after adjusting for social and clinical factors relating to admission. The finding that Black CYP are more than twice as likely to experience involuntary admission is in keeping with prior literature in CYP and the adult literature. This racial inequity requires further investigation to address disparities in access to mental health care and application of the MHA.

In England, a range of mental health crisis care models and approaches to organising crisis care systems have been implemented, but characteristics associated with their effectiveness are poorly understood.

To (a) develop a typology of catchment area mental health crisis care systems and (b) investigate how crisis care service models and system characteristics relate to psychiatric hospital admissions and detentions.

Crisis systems data were obtained from a 2019 English national survey. Latent class analyses were conducted to identify discernible typologies, and mixed-effects negative binomial regression models were fitted to explore associations between crisis care models and admissions and detention rates, obtained from nationally reported data.

No clear typology of catchment area crisis care systems emerged. Regression models suggested that provision of a crisis telephone service within the local crisis system was associated with a 11.6% lower admissions rate and 15.3% lower detention rate. Provision of a crisis cafe was associated with a 7.8% lower admission rates. The provision of a crisis assessment team separate from the crisis resolution and home treatment service was associated with a 12.8% higher admission rate.

The configuration of crisis care systems varies considerably in England, but we could not derive a typology that convincingly categorised crisis care systems. Our results suggest that a crisis phone line and a crisis cafe may be associated with lower admission rates. However, our findings suggest crisis assessment teams, separate from home treatment teams, may not be associated with reductions in admission and detentions.

Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units.

This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units.

We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies – of Interventions and Risk of Bias in Randomized Trials.

Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ2 = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI −261.24 to −67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43–0.68; P < 0.001).

Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.

We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).

Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother–infant interaction quality and safeguarding outcome.

Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86–1.04, P = 0.29; an absolute difference of −5%, 95% CI −14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.

We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes.

Mental health crises are common in people with complex emotional needs (our preferred working term for people diagnosed with a 'personality disorder'), yet this population is often dissatisfied with the crisis care they receive. Exploring their experiences and views on what could be improved, and those of carers and healthcare staff, is key to developing better services.

We aimed to synthesise the relevant qualitative literature.

Five databases were searched. Eligible studies included service users with a diagnosis of personality disorder and their carers or relevant staff, focused on crisis responses and used a qualitative design. Data were analysed with thematic synthesis.

Eleven studies were included, most focusing on emergency departments. Four meta-themes emerged: (a) acceptance and rejection when presenting to crisis care: limited options and lack of involvement of carers; (b) interpersonal processes: importance of the therapeutic relationship and establishing a framework for treatment; (c) managing recovery from a crisis: clear recovery plan and negotiating collaboration; and (d) equipping and supporting staff: training and emotional support.

Our findings suggest that emergency departments have major limitations as settings to provide crisis care for people with complex emotional needs, but there is a lack of research exploring alternatives. The quality of the therapeutic relationship was central to how care was experienced, with collaborative and optimistic staff highly valued. Staff reported feeling poorly supported in responding to the needs of this population. Research looking at experiences of a range of care options and how to improve these is needed.

Diagnoses of personality disorder are prevalent among people using community secondary mental health services. Identifying cost-effective community-based interventions is important when working with finite resources.

To assess the cost-effectiveness of primary or secondary care community-based interventions for people with complex emotional needs who meet criteria for a diagnosis of personality disorder to inform healthcare policy-making.

Systematic review (PROSPERO: CRD42020134068) of databases. We included economic evaluations of interventions for adults with complex emotional needs associated with a diagnosis of personality disorder in community mental health settings published before 18 September 2019. Study quality was assessed using the CHEERS statement.

Eighteen studies were included. The studies mainly evaluated psychotherapeutic interventions. Studies were also identified that evaluated altering the setting in which care was delivered and joint crisis plans. No strong economic evidence to support a single intervention or model of community-based care was identified.

Robust economic evidence to support a single intervention or model of community-based care for people with complex emotional needs is lacking. The strongest evidence was for dialectical behaviour therapy, with all three identified studies indicating that it is likely to be cost-effective in community settings compared with treatment as usual. More robust evidence is required on the cost-effectiveness of community-based interventions on which decision makers can confidently base guidelines or allocate resources. The evidence should be based on consistent measures of costs and outcomes with sufficient sample sizes to demonstrate impacts on these.

In the UK, acute mental healthcare is provided by in-patient wards and crisis resolution teams. Readmission to acute care following discharge is common. Acute day units (ADUs) are also provided in some areas.

To assess predictors of readmission to acute mental healthcare following discharge in England, including availability of ADUs.

We enrolled a national cohort of adults discharged from acute mental healthcare in the English National Health Service (NHS) between 2013 and 2015, determined the risk of readmission to either in-patient or crisis teams, and used multivariable, multilevel logistic models to evaluate predictors of readmission.

Of a total of 231 998 eligible individuals discharged from acute mental healthcare, 49 547 (21.4%) were readmitted within 6 months, with a median time to readmission of 34 days (interquartile range 10–88 days). Most variation in readmission (98%) was attributable to individual patient-level rather than provider (trust)-level effects (2.0%). Risk of readmission was not associated with local availability of ADUs (adjusted odds ratio 0.96, 95% CI 0.80–1.15). Statistically significant elevated risks were identified for participants who were female, older, single, from Black or mixed ethnic groups, or from more deprived areas. Clinical predictors included shorter index admission, psychosis and being an in-patient at baseline.

Relapse and readmission to acute mental healthcare are common following discharge and occur early. Readmission was not influenced significantly by trust-level variables including availability of ADUs. More support for relapse prevention and symptom management may be required following discharge from acute mental healthcare.

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.

Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change.

To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals.

Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed.

Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures.

In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%).

Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.

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.

Carers are key providers of care and support to mental health patients and mental health policies consistently mandate carer involvement. Understanding carers' experiences of and views about assessment for involuntary admission and subsequent detention is crucial to efforts to improve policy and practice.

We aimed to synthesise qualitative evidence of carers' experiences of the assessment and detention of their family and friends under mental health legislation.

We searched five bibliographic databases, reference lists and citations. Studies were included if they collected data using qualitative methods and the patients were aged 18 or older; reported on carer experiences of assessment or detention under mental health legislation anywhere in the world; and were published in peer-reviewed journals. We used meta-synthesis.

The review included 23 papers. Themes were consistent across time and setting and related to the emotional impact of detention; the availability of support for carers; the extent to which carers felt involved in decision-making; relationships with patients and staff during detention; and the quality of care provided to patients. Carers often described conflicting feelings of relief coupled with distress and anxiety about how the patient might cope and respond. Carers also spoke about the need for timely and accessible information, supportive and trusting relationships with mental health professionals, and of involvement as partners in care.

Research is needed to explore whether and how health service and other interventions can improve the involvement and support of carers prior to, during and after the detention of family members and friends.

Evidence-informed planning and interpretation of research results both require standardised description of local care delivery context. Such context analysis descriptions should be comparable across regions and countries to allow benchmarking and organizational learning, and for research findings to be interpreted in context. The European Service Mapping Schedule (ESMS) is a classification of adult mental health services that was later adapted for the assessment of health and social systems research (Description and Evaluation of Services and DirectoriEs - DESDE). The aim of the study was to review the diffusion and use of the ESMS/DESDE system in health and social care and its impact in health policy and decision-making.

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (1997–2018).

Out of 155 papers mentioning ESMS/DESDE, 71 have used it for service research and planning. The classification has been translated into eight languages and has been used by seven international research networks. Since 2000, it has originated 11 instruments for health system research with extensive analysis of their metric properties. The ESMS/DESDE coding system has been used in 585 catchment areas in 34 countries for description of services delivery at local, regional and national levels.

The ESMS/DESDE system provides a common terminology, a classification of care services, and a set of tools allowing a variety of aims to be addressed in healthcare and health systems research. It facilitates comparisons across and within countries for evidence-informed planning.

Mental health services lack a strong evidence base on the most effective interventions to reduce compulsory admissions. However, some research suggests a positive impact of crisis-planning interventions in which patients are involved in planning for their future care during a mental health crisis.

This review aimed to synthesise randomised controlled trial (RCT) evidence on the effectiveness of crisis-planning interventions (for example advance statements and joint crisis plans) in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder, compared with usual care (PROSPERO registration number: CRD42018084808).

Six online databases were searched in October 2018. The primary outcome was compulsory psychiatric admissions and secondary outcomes included other psychiatric admissions, therapeutic alliance, perceived coercion and cost-effectiveness. Bias was assessed using the Cochrane collaboration tool.

The search identified 1428 studies and 5 RCTs were eligible. One study had high risk of bias because of incomplete primary outcome data. Random-effects meta-analysis showed a 25% reduction in compulsory admissions for those receiving crisis-planning interventions compared with usual care (risk ratio 0.75, 95% CI 0.61–0.93, P = 0.008; from five studies). There was no statistical evidence that the intervention reduced the risk of voluntary or combined voluntary and compulsory psychiatric admissions. Few studies assessed other secondary outcomes.

Our meta-analysis suggests that crisis-planning interventions substantially reduce the risk of compulsory admissions among individuals with psychotic illness or bipolar disorder. Despite common components, interventions varied in their content and intensity across the trials. The optimal models and implementation of these interventions require further investigation.

E.M., S.L., S.J. and B.L.-E. received funding from the National Institute for Health Research during the conduct of the study.