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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.
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.
Design, setting, and participants:
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.
Trends in detention under the Mental Health Act 1983 in two major London secondary mental healthcare providers were explored using patient-level data in a historical cohort study between 2007–2008 and 2016–2017. An increase in the number of detention episodes initiated per fiscal year was observed at both sites. The rise was accompanied by an increase in the number of active patients; the proportion of active patients detained per year remained relatively stable. Findings suggest that the rise in the number of detentions reflects the rise of the number of people receiving secondary mental healthcare.
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.
Declaration of interest
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.
Concerns are recurrently expressed that the therapeutic content of in-patient care is limited and lacking clear guidance. The perspectives of patients and staff regarding therapeutic priorities for psychiatric in-patient care have been little explored and compared.
The aim of this study was to examine patient and staff perspectives on the care priorities of psychiatric in-patients with psychosis.
We recruited 12 in-patients with psychosis and 12 multidisciplinary team staff. All participants undertook a semi-structured interview examining their perspectives on the therapeutic needs of people with psychosis during admission. Interviews were transcribed verbatim and thematic analysis conducted.
Three superordinate themes arose from patient interviews: ‘the importance of considering social circumstances and trauma’, ‘managing the intra- and interpersonal impact of psychosis’ and ‘lack of control and collaboration in care’ and three from staff interviews: ‘multidisciplinary facilitators of care’, ‘treating complexity and incorporating social factors’ and ‘restrictive practices preventing quality care provision’. Comparison of patient and staff themes identified unmet needs in addressing social marginalisation, trauma and distress, and the importance of collaborative treatment process and inclusion of spirituality.
There are gaps between staff and patient perspectives on important priorities for in-patient care that may help explain persistent patient dissatisfaction with in-patient care. Findings suggest the need for coproduced work to develop and test interventions that address broader therapeutic priorities.
Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.
To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.
Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.
The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.
Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.
Self-management is intended to empower individuals in their recovery by providing the skills and confidence they need to take active steps in recognising and managing their own health problems. Evidence supports such interventions in a range of long-term physical health conditions, but a recent systematic synthesis is not available for people with severe mental health problems.
To evaluate the effectiveness of self-management interventions for adults with severe mental illness (SMI).
A systematic review of randomised controlled trials was conducted. A meta-analysis of symptomatic, relapse, recovery, functioning and quality of life outcomes was conducted, using RevMan.
A total of 37 trials were included with 5790 participants. From the meta-analysis, self-management interventions conferred benefits in terms of reducing symptoms and length of admission, and improving functioning and quality of life both at the end of treatment and at follow-up. Overall the effect size was small to medium. The evidence for self-management interventions on readmissions was mixed. However, self-management did have a significant effect compared with control on subjective measures of recovery such as hope and empowerment at follow-up, and self-rated recovery and self-efficacy at both time points.
There is evidence that the provision of self-management interventions alongside standard care improves outcomes for people with SMI. Self-management interventions should form part of the standard package of care provided to people with SMI and should be prioritised in guidelines: research on best methods of implementing such interventions in routine practice is needed.
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.
A national survey investigated the implementation of mental health crisis resolution teams (CRTs) in England. CRTs were mapped and team managers completed an online survey.
Ninety-five per cent of mapped CRTs (n = 233) completed the survey. Few CRTs adhered fully to national policy guidelines. CRT implementation and local acute care system contexts varied substantially. Access to CRTs for working-age adults appears to have improved, compared with a similar survey in 2012, despite no evidence of higher staffing levels. Specialist CRTs for children and for older adults with dementia have been implemented in some areas but are uncommon.
A national mandate and policy guidelines have been insufficient to implement CRTs fully as planned. Programmes to support adherence to the CRT model and CRT service improvement are required. Clearer policy guidance is needed on requirements for crisis care for young people and older adults.
Background: Perinatal mental health difficulties are highly prevalent. In England, the Improving Access to Psychological Therapy (IAPT) programme provides evidence-based psychological treatment, predominantly in the form of brief manualized cognitive behavioural therapy (CBT), to people with mild to moderate depression or anxiety. Yet little is known about the experiences of women referred to IAPT with perinatal mental health difficulties. Aims: The aim of this qualitative study was to investigate how women view IAPT support for perinatal mental health. We also gained the perspective of IAPT therapists. Method: Semi-structured interviews were conducted with twelve women who had been referred to and/or received therapy from IAPT during the perinatal period. Additionally, fourteen IAPT therapists participated in two focus groups. Thematic analysis was used. Results: Key themes centred on barriers to access and the need to tailor support to (expectant) mothers. Women and therapists suggested that experiences could be improved by supporting healthcare professionals to provide women with more help with referrals, better tailoring support to the perinatal context, improving perinatal-specific training, supervision and resources, and offering a more individualized treatment environment. Conclusions: Overall, women reported positive experiences of support offered by IAPT for perinatal mental health difficulties. However, services should seek to facilitate access to support and to enable therapists to better tailor treatment.
Caregiver satisfaction and experience surveys help health professionals to understand, measure, and improve the quality of care provided for patients and their families.
Our aim was to explore caregiver perceptions of the care received from Australian specialist palliative care services.
Caregivers of patients receiving palliative care in services registered with Australia's Palliative Care Outcomes Collaboration were invited to participate in a caregiver survey. The survey included the FAMCARE–2 and four items from the Ongoing Needs Identification: Caregiver Profile questionnaire.
Surveys were completed by 1,592 caregivers from 49 services. Most respondents reported high satisfaction and positive experiences. Caregivers receiving care from community-based palliative care teams were less satisfied with the management of physical symptoms and comfort (odds ratio [OR] = 0.29; 95% confidence interval [CI95%] = 0.14, 0.59), with patient psychological care (OR = 0.56; CI95% = 0.32, 0.98), and with family support (OR = 0.52; CI95% = 0.35, 0.77) than caregivers of patients in an inpatient setting. If aged over 60 years, caregivers were less likely to have their information needs met regarding available support services (OR = 0.98; CI95% = 0.97, 0.98) and carer payments (OR = 0.99; CI95% = 0.98, 1.00). Also, caregivers were less likely to receive adequate information about carer payments if located in an outer regional area (OR = 0.41; CI95% = 0.25, 0.64). With practical training, caregivers receiving care from community services reported inadequate information provision to support them in caring for patients (OR = 0.60; CI95% = 0.45, 0.81).
Significance of Results:
While our study identified caregivers as having positive and satisfactory experiences across all domains of care, there is room for improvement in the delivery of palliative care across symptom management, as well as patient and caregiver support, especially in community settings. Caregiver surveys can facilitate the identification and evaluation of both patients' and caregivers' experiences, satisfaction, distress, and unmet needs.
A needs-led approach to the provision of mental healthcare has been one of the most consistent themes to emerge within evolving community mental healthcare services. In England this was first expressed in the provisions of the National Health Service and Community Care Act 1990. The central tenet of a needs-led approach is that assessment of the needs of patients should be on the basis of their individual circumstances, problems and personal goals. Assessment should not be undertaken in terms of or on the basis of existing services, that is, assessment should not be service based. This means that assessment of need is a separate process from decisions about what care or treatment to provide.
Needs-led assessment should, for example, look at whether people have access to enough activities which are meaningful (to them) each day, rather than whether they need to attend a day centre. If the assessment indicates that there is a problem with daytime activities, one service response might be a place at a day centre. Another, however, might be support in undertaking voluntary work. Needs-led assessments have two advantages over service-based assessments: first, they point to the most appropriate form of service response (in terms of treatment or care) for the individual's difficulties; and second, they have the potential to indicate needs for which there is currently no service provision, which a service-based assessment by definition would not identify.
What is a need?
People with severe mental illness usually have a wide range of clinical and social needs. A variety of approaches to defining need have been proposed. The American psychologist Maslow (1954) established a hierarchy of need when attempting to formulate a theory of human motivation. In Maslow's model, fundamental physiological needs (such as the need for food) underpin the higher needs of safety, love, self-esteem and self-actualisation. He proposed that people are motivated by the requirement to meet these needs, and that higher needs could be met only after the lower and more fundamental needs were met. This approach can be illustrated by the example of a homeless man, who is not concerned about his lack of friends while he is cold and hungry. However, once these physiological needs have been met he may express more interest in having the company of other people.
There is now an established evidence base for the use of information and communication technology (ICT) to support mental healthcare (‘e-mental health’) for common mental health problems. Recently, there have been significant developments in the therapeutic use of computers, mobile phones, gaming and virtual reality technologies for the assessment and treatment of psychosis. We provide an overview of the therapeutic use of ICT for psychosis, drawing on searches of the scientific literature and the internet and using interviews with experts in the field. We outline interventions that are already relevant to clinical practice, some that may become available in the foreseeable future and emerging challenges for their implementation.
A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.
People with mental illness are at increased risk of intimate partner violence (IPV) victimisation, but little is known about their risk for different forms of IPV, related health impact and help-seeking.
To estimate the odds for past-year IPV, related impact and disclosure among people with and without pre-existing chronic mental illness (CMI).
We analysed data from 23 222 adult participants in the 2010/2011 British Crime Survey using multivariate logistic regression.
Past-year IPV was reported by 21% and 10% of women and men with CMI, respectively. The adjusted relative odds for emotional, physical and sexual IPV among women with versus without CMI were 2.8 (CI = 1.9–4.0), 2.6 (CI = 1.6–4.3) and 5.4 (CI = 2.4–11.9), respectively. People with CMI were more likely to attempt suicide as result of IPV (aOR = 5.4, CI = 2.3–12.9), less likely to seek help from informal networks (aOR = 0.5, CI = 0.3–0.8) and more likely to seek help exclusively from health professionals (aOR = 6.9, CI = 2.6–18.3)
People with CMI are not only at increased risk of all forms of IPV, but they are more likely to suffer subsequent ill health and to disclose exclusively to health professionals. Therefore, health professionals play a key role in addressing IPV in this population.