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The boundary between services for children and adolescents and adults has been identified as problematic for young people with mental health problems.
To examine the use and cost of healthcare for young people engaged in mental healthcare before and after the child/adolescent and adult service boundary.
Data from 772 young people in seven European countries participating in the MILESTONE trial were analysed. We analysed and costed healthcare resources used in the 6-month period before and after the service boundary.
The proportion of young people engaging with healthcare services fell substantially after crossing the service boundary (associated costs €7761 pre-boundary v. €3376 post-boundary). Pre-boundary, the main cost driver was in-patient care (approximately 50%), whereas post-boundary costs were more evenly spread between services; cost reductions were correlated with pre-boundary in-patient care. Severity was associated with substantially higher costs pre- and post-boundary, and those who were engaged specifically with mental health services after the service boundary accrued the greatest healthcare costs post-service boundary.
Costs of healthcare are large in this population, but fall considerably after transition, particularly for those who were most severely ill. In part, this is likely to reflect improvement in the mental health of young people. However, qualitative evidence from the MILESTONE study suggests that lack of capacity in adult services and young people's disengagement with formal mental health services post-transition are contributing factors. Long-term data are needed to assess the adverse long-term effects on costs and health of this unmet need and disengagement.
This paper introduces the TRANSFORM project, which aims to improve access to mental health services for people with serious and enduring mental disorders (SMDs – psychotic disorders and severe mood disorders, often with co-occurring substance misuse) living in urban slums in Dhaka (Bangladesh) and Ibadan (Nigeria). People living in slum communities have high rates of SMDs, limited access to mental health services and conditions of chronic hardship. Help is commonly sought from faith-based and traditional healers, but people with SMDs require medical treatment, support and follow-up. This multicentre, international mental health mixed-methods research project will (a) conduct community-based ethnographic assessment using participatory methods to explore community understandings of SMDs and help-seeking; (b) explore the role of traditional and faith-based healing for SMDs, from the perspectives of people with SMDs, caregivers, community members, healers, community health workers (CHWs) and health professionals; (c) co-design, with CHWs and healers, training packages for screening, early detection and referral to mental health services; and (d) implement and evaluate the training packages for clinical and cost-effectiveness in improving access to treatment for those with SMDs. TRANSFORM will develop and test a sustainable intervention that can be integrated into existing clinical care and inform priorities for healthcare providers and policy makers.
Early COVID-19 research suggests a detrimental impact of the initial lockdown on young people's mental health.
We investigated mental health among university students and young adults after the first UK lockdown and changes in symptoms over 6 months.
In total, 895 university students and 547 young adults not in higher education completed an online survey at T1 (July–September 2020). A subset of 201 university students also completed a 6 month follow-up survey at T2 (January–March 2021). Anxiety, depression, insomnia, substance misuse and suicide risk were assessed.
At T1, approximately 40%, 25% and 33% of the participants reported moderate to severe anxiety and depression and substance misuse risk, clinically significant insomnia and suicidal risk. In participants reassessed at T2, reductions were observed in anxiety and depression but not in insomnia, substance misuse or suicidality. Student and non-student participants reported similar levels of mental health symptoms. Student status was not a significant marker of mental health symptoms, except for lower substance misuse risk.
Cross-sectionally, greater symptoms across measures were consistently associated with younger age, pre-existing mental health conditions, being a carer, worse financial status, increased sleep irregularity and difficulty since lockdown. Longitudinally, T2 symptoms were consistently associated with worse financial status and increased difficulty sleeping at T1. However, these associations were attenuated when baseline mental health symptoms were adjusted for in the models.
Mental health symptoms were prevalent in a large proportion of young people after the first UK lockdown. Risk factors identified may help characterise high-risk groups for enhanced support and inform interventions.
Mindfulness-based therapies (MBTs) have shown promising results in non-psychotic disorders. Unlike most other psychotherapy models, which are claimed to be Western in origin, MBTs are firmly based in Indian philosophy and traditions. This paper summarises the concepts of the observer self (sakshi) and attention (dhyana) that underlie the principles and practice of MBT, correcting some erroneous assumptions in the process. It is argued that better understanding of these concepts is beneficial not just for specialist psychotherapists, but for all clinicians interested in the craft of healing.
The four main Indian religions – Hinduism, Buddhism, Jainism and Sikhism – have several shared concepts about self and suffering, which are salient to the world-view of the followers of these faiths. Understanding the concepts of mind, self and suffering in these faiths can help clinicians build better rapport and gain deeper understanding of the inner world of patients of these faiths. This article highlights the broad cultural and religious beliefs of these groups, with the hope that increased knowledge among clinicians might lead to better therapeutic engagement.
Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics.
This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services.
Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points.
A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine.
Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.
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.
Occupational participation is important for personality disordered offenders (PDOs) because it is integral to health and desistance from offending. What influences occupational participation is unknown for PDOs in the community, limiting effective intervention to affect change. In England and Wales, the Offender Personality Disorder Pathway aims to improve outcomes for people considered highly likely to have a severe personality disorder and who present a high risk of reoffending, who are determined to be PDOs on the basis of a structured assessment. This study identified the influencers of occupational participation for the population who receive this service.
In this critical realist, qualitative study, narrative interviews were conducted with 18 PDOs supervised by probation in England. Transcripts were analyzed using a grounded theory approach to establish influencers of occupational participation.
Four themes describe influencers of occupational participation: function of occupations; influence of the past; external forces; and learning and adaptation. The latter theme reflected understandings of occupational adaptation described by the Model of Human Occupation.
An intervention to increase prosocial occupational participation should be developed and evaluated for PDOs in the community, taking account of occupational participation over the life course.
Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.
To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).
We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).
A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1–9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9–11.3%) compared with LMICs (4.3%, 95% CI 2.6–6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).
Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.
Somaliland is experiencing an explosion of mental health problems that has received little coverage. The country has experienced devastating civil wars that have resulted in widespread trauma, and the lack of necessary mental health infrastructure is an obstacle to allowing the population to heal and recover. War trauma, poverty, unemployment and widespread substance misuse (khat) have all negatively affected the mental health of its citizens. This report provides an overview of a rapid needs assessment carried out across Somaliland that examined current service provision, gaps in services, and interviews with mental health professionals and caregivers.
Conventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.
Declaration of interest
All authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Department of Health. S.P.S. is part funded by Collaboration for Leadership in Applied Health Research and Care West Midlands. K.B. is editor of the British Journal of Psychiatry.
The appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available.
As part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals' understanding of the ATT, and its impact on clinical practice.
Forty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process.
We found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient's age rather than diagnosis. The ATT has had little impact on clinical practice.
Our findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended.
The Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK) study was a multistage, multicentre study of adolescents' transitions between child and adult mental health services undertaken in England. We conducted a secondary analysis of the TRACK study data to investigate healthcare provision for young people (n = 64) with ongoing mental health needs, who were not transferred from child and adolescent mental health services (CAMHS) to adult mental health services mental health services (AMHS).
The most common outcomes were discharge to a general practitioner (GP; n =29) and ongoing care with CAMHS (n = 13), with little indication of use of third-sector organisations. Most of these young people had emotional/neurotic disorders (n = 31, 48.4%) and neurodevelopmental disorders (n = 15, 23.4%).
GPs and CAMHS are left with the responsibility for the continuing care of young people for whom no adult mental health service could be identified. GPs may not be able to offer the skilled ongoing care that these young people need. Equally, the inability to move them decreases the capacity of CAMHS to respond to new referrals and may leave some young people with only minimal support.
High-quality services for people with psychosis are essential. However, in
this debate David Castle questions whether separate early intervention
services are the best option and argues instead for an integrated approach.
Swaran Singh responds, robustly defending the value of early intervention
Communication may be an influential determinant of inequality of access to, engagement with and benefit from psychiatric services.
To review the evidence on interventions designed to improve therapeutic communications between Black and minority ethnic patients and clinicians who provide care in psychiatric services.
Systematic review and evidence synthesis (PROSPERO registration: CRD42011001661). Data sources included the published and the ‘grey’ literature. A survey of experts and a consultation with patients and carers all contributed to the evidence synthesis, interpretation and recommendations.
Twenty-one studies were included in our analysis. The trials showed benefits mainly for depressive symptoms, experiences of care, knowledge, stigma, adherence to prescribed medication, insight and alliance. The effect sizes were smaller for better-quality trials (range of d 0.18–0.75) than for moderate- or lower-quality studies (range of d 0.18–4.3). The review found only two studies offering weak economic evidence.
Culturally adapted psychotherapies, and ethnographic and motivational assessment leading to psychotherapies were effective and favoured by patients and carers. Further trials are needed from outside of the UK and USA, as are economic evaluations and studies of routine psychiatric care practices.
Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.
To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.
Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.
A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.
Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.
Sampling techniques for national surveys have constrained the statistical power in estimating prevalence rates of child mental health problems in minority ethnic groups.
To establish the prevalence rates of mental health problems in ethnic Indian adolescents in England and compare these with matched White adolescents living in the same areas.
A cross-sectional survey with oversampling of Indian adolescents aged 13–15 years of age.
The sample size was 2900 (71% response rate) with 1087 (37%) Indian and 414 (14%) White adolescents. Ethnically Indian adolescents had lower rates of all types of mental
health problems (5% v. 13% and 21% v. 30% for abnormal Strengths and Difficulties Questionnaire and Short Mood and Feelings Questionnaire scores, respectively) and substance misuse (18% v. 57%, 5% v. 15% and 6% v. 9% for regular alcohol, smoking and drug use, respectively), with the exception of eating disorders, compared with their White counterparts. The odds of an abnormal score on the mental health questionnaires were worse for White compared with Indian children irrespective of sociodemographic variables.
Factors relating to how Indian adolescents are parented or their social support networks may be influencing their mental health and may warrant further investigation.