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Previous studies in individual countries have identified inconsistent predictors of length of stay (LoS) in psychiatric inpatient units. This may reflect methodological inconsistencies across studies or true differences of predictors. In this study we assessed predictors of LoS in five European countries and explored whether their effect varies across countries.
Prospective cohort study. All patients admitted over 14 months to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and United Kingdom were screened. Putative predictors were collected from medical records and in face-to-face interviews and tested for their association with LoS.
Average LoS varied from 17.9 days in Italy to 55.1 days in Belgium. In the overall sample being homeless, receiving benefits, social isolation, diagnosis of psychosis, greater symptom severity, substance use, history of previous admission and being involuntarily admitted predicted longer LoS. Several predictors showed significant interaction effects with countries in predicting LoS. One variable, homelessness, predicted a different LoS even in opposite directions, whilst for other predictors the direction of the association was the same, but the strength of the association with LoS varied across countries.
The same patient characteristics have a different impact on LoS in different contexts. Thus, although some predictor variables related to clinical severity and social dysfunction appear of generalisable relevance, national studies on LoS are required to understand the complex influence of different patient characteristics on clinical practice in the given contexts.
Patient satisfaction is a key indicator of inpatient care quality and is associated with clinical outcomes following admission. Different patient characteristics have been inconsistently linked with satisfaction. This study aims to overcome previous limitations by assessing which patient characteristics are associated with satisfaction within a large study of psychiatric inpatients conducted across five European countries.
All patients with a diagnosis of psychotic (F2), affective (F3) or anxiety/somataform (F4) disorder admitted to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and the UK were included. Data were collected from medical records and face-to-face interviews, with patients approached within 2 days of admission. Satisfaction with inpatient care was measured on the Client Assessment of Treatment Scale.
Higher satisfaction scores were associated with being older, employed, living with others, having a close friend, less severe illness and a first admission. In contrast, higher education levels, comorbid personality disorder and involuntary admission were associated with lower levels of satisfaction. Although the same patient characteristics predicted satisfaction within the five countries, there were significant differences in overall satisfaction scores across countries. Compared to other countries, patients in the UK were significantly less satisfied with their inpatient care.
Having a better understanding of patient satisfaction may enable services to improve the quality of care provided as well as clinical outcomes for all patients. Across countries, the same patient characteristics predict satisfaction, suggesting that similar analytical frameworks can and should be used when assessing satisfaction both nationally and internationally.
In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country’s health system. Since personal continuity would be more suitable for patients with complex psychosocial needs, the aim of this study was to identify predictors of patients’ exposure to care approaches in different European countries.
Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge, patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients’ discharge were assessed in both groups of countries.
Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population.
Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless, organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.
There is an emerging evidence base about best practice in supporting
recovery. This is usually framed in relation to general principles, and
specific pro-recovery interventions are lacking.
To develop a theoretically based and empirically defensible new
pro-recovery manualised intervention – called the REFOCUS
Seven systematic and two narrative reviews were undertaken. Identified
evidence gaps were addressed in three qualitative studies. The findings
were synthesised to produce the REFOCUS intervention, manual and
The REFOCUS intervention comprises two components: recovery-promoting
relationships and working practices. Approaches to supporting
relationships comprise coaching skills training for staff, developing a
shared team understanding of recovery, exploring staff values, a
Partnership Project with people who use the service and raising patient
expectations. Working practices comprise the following: understanding
values and treatment preferences; assessing strengths; and supporting
goal-striving. The REFOCUS model describes the causal pathway from the
REFOCUS intervention to improved recovery.
The REFOCUS intervention is an empirically supported pro-recovery
intervention for use in mental health services. It will be evaluated in a
multisite cluster randomised controlled trial (ISRCTN02507940).
Supporting recovery is the aim of national mental health policy in many
countries. However, only one measure of recovery has been developed in
England: the Questionnaire about the Process of Recovery (QPR), which
measures recovery from the perspective of adult mental health service
users with a psychosis diagnosis.
To independently evaluate the psychometric properties of the 15- and
22-item versions of the QPR.
Two samples were used: data-set 1 (n = 88) involved
assessment of the QPR at baseline, 2 weeks and 3 months. Data-set 2
(n = 399; trial registration: ISRCTN02507940)
involved assessment of the QPR at baseline and 1 year.
For the 15-item version, internal consistency was 0.89, convergent
validity was 0.73, test–retest reliability was 0.74 and sensitivity to
change was 0.40. Confirmatory factor analysis showed the 15-item version
offered a good fit. For the 22-item version, the interpersonal subscale
was found to underperform and the intrapersonal subscale overlaps
substantially with the 15-item version.
Both the 15-item and the intrapersonal subscale of the 22-item versions
of the QPR demonstrated satisfactory psychometric properties. The 15-item
version is slightly more robust and also less burdensome, so it can be
recommended for use in research and clinical practice.
The feasibility of implementation is insufficiently considered in
clinical guideline development, leading to human and financial resource
To develop (a) an empirically based standardised measure of the
feasibility of complex interventions for use within mental health
services and (b) reporting guidelines to facilitate feasibility
A focused narrative review of studies assessing implementation blocks and
enablers was conducted with thematic analysis and vote counting used to
determine candidate items for the measure. Twenty purposively sampled
studies (15 trial reports, 5 protocols) were included in the psychometric
evaluation, spanning different interventions types. Cohen's kappa (κ) was
calculated for interrater reliability and test–retest reliability.
In total, 95 influences on implementation were identified from 299
references. The final measure – Structured Assessment of FEasibility
(SAFE) – comprises 16 items rated on a Likert scale. There was excellent
interrater (κ = 0.84, 95% CI 0.79–0.89) and test–retest reliability (κ =
0.89, 95% CI 0.85–0.93). Cost information and training time were the two
influences least likely to be reported in intervention papers. The SAFE
reporting guidelines include 16 items organised into three categories
(intervention, resource consequences, evaluation).
A novel approach to evaluating interventions, SAFE, supplements efficacy
and health economic evidence. The SAFE reporting guidelines will allow
feasibility of an intervention to be systematically assessed.
Two recent meta-analyses claim that abortion leads to a deterioration in mental health. Previous reviews concluded that the mental health outcomes following an unwanted pregnancy are much the same whether the woman gives birth or terminates the pregnancy, although there is an increased mental health risk with an unwanted pregnancy. Meta-analysis is particularly susceptible to bias in this area. The physical health outcomes for women with an unwanted pregnancy have improved greatly by making abortion legal. To further improve the mental health outcomes associated with an unwanted pregnancy we should focus practice and research on the individual needs of women with an unwanted pregnancy, rather than how the pregnancy is resolved.
No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken.
To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.
Systematic review and modified narrative synthesis.
Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery.
The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.
Antidepressant drugs are widely used in the treatment of depression in
people with chronic physical health problems.
To examine evidence related to efficacy, tolerability and safety of
antidepressants for people with depression and with chronic physical
Meta-analyses of randomised controlled efficacy trials of antidepressants
in depression in chronic physical health conditions. Systematic review of
Sixty-three studies met inclusion criteria (5794 participants). In
placebo-controlled studies, antidepressants showed a significant
advantage in respect to remission and/or response: selective serotonin
reuptake inhibitors (SSRIs) risk ratio (RR) = 0.81 (95% CI 0.73–0.91) for
remission, RR = 0.83 (95% CI 0.71–0.97) for response; tricyclics RR =
0.70 (95% CI 0.40–1.25 (not significant)) for remission, RR = 0.55 (95%
0.43–0.70) for response. Both groups of drugs were less well tolerated
than placebo (leaving study early due to adverse effects) for SSRIs RR =
1.80 (95% CI 1.16–2.78), for tricyclics RR = 2.00 (95% CI 0.99–3.57).
Only SSRIs were shown to improve quality of life. Direct comparisons of
SSRIs and tricyclics revealed no advantage for either group for
remission, response, effect size or tolerability. Effectiveness studies
suggest a neutral or beneficial effect on mortality for antidepressants
in participants with recent myocardial infarction.
Antidepressants are efficacious and safe in the treatment of depression
occurring in the context of chronic physical health problems. The SSRIs
are probably the antidepressants of first choice given their demonstrable
effect on quality of life and their apparent safety in cardiovascular
Early intervention services for psychosis aim to detect emergent symptoms, reduce the duration of untreated psychosis, and improve access to effective treatments.
To evaluate the effectiveness of early intervention services, cognitive–behavioural therapy (CBT) and family intervention in early psychosis.
Systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis.
Early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. Used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission.
For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period. The longer-term benefits of this approach and its component treatments for people with early and established psychosis need further research.
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