RSS 1.0Adult Mental Health
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The development of the Compassion Focused Therapy Therapist Competence Rating ScaleObjectives Compassion-focused therapy (CFT) has shown promise as a treatment for a number of clinical presentations; however, existing studies have not adequately addressed issues of treatment fidelity. The aims of the present study were to identify initial candidate items that may be included in a CFT therapist competence rating scale and to develop the behavioural indicators to anchor these items. Design The Delphi method was used to develop and operationalize the competencies required for inclusion in a CFT therapist competence rating scale over five rounds. Methods Face-to-face meetings with two CFT experts were conducted in rounds one, two, and five, and these were used to define and operationalize the competencies. Nine other CFT experts were invited to complete online surveys in rounds two and four. An 80% consensus level was applied to the online surveys. Results The resulting Compassion Focused Therapy Therapist Competence Rating Scale (CFT-TCRS) consisted of 23 competencies which were separated into 14 ‘CFT unique competencies’ and nine ‘Microskills’. There was high agreement about the included ‘CFT unique competencies’ and ‘Microskills’; however, there were some differences in opinion about the specific content of some items. Conclusions This is the first study that has attempted to reach consensus regarding the competencies and behavioural anchors for a CFT therapist competence rating scale. The next stage of development for the CFT-TCRS is to establish whether the scale can be reliably and validly used to evaluate CFT practice.
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Air Pollution: an environmental risk factor for psychiatric illness?No abstract is available for this article.
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Interventions for mental health problems in children and adults with severe intellectual disabilities: a systematic review.Objective: Mental health problems are more prevalent in people with than without intellectual disabilities, yet treatment options have received little attention. The aim of this study was to identify and evaluate the effectiveness of pharmacological and psychological interventions in the treatment of mental health problems in children and adults with severe and profound intellectual disabilities, given their difficulties in accessing standard mental health interventions, particularly talking therapies, and difficulties reporting drug side effects. Design: A systematic review using electronic searches of PsycINFO, PsycTESTS, EMBASE, MEDLINE, CINAHL, ERIC, ASSIA, Science Citation Index, Social Science Citation Index and CENTRAL was conducted to identify eligible intervention studies. Study selection, data extraction and quality appraisal were performed by two independent reviewers. Participants: Study samples included at least 70% children and/or adults with severe or profound intellectual disabilities or reported the outcomes of this subpopulation separate from participants with other levels of intellectual disabilities. Interventions: Eligible intervention studies evaluated a psychological or pharmacological intervention using a control condition or pre-post design. Outcomes: Symptom severity, frequency or other quantitative dimension (e.g., impact), as assessed with standardised measures of mental health problems. Results: We retrieved 41 232 records, reviewed 573 full-text articles and identified five studies eligible for inclusion: three studies evaluating pharmacological interventions, and two studies evaluating psychological interventions. Study designs ranged from double-blind placebo controlled crossover trials to single-case experimental reversal designs. Quality appraisals of this very limited literature base revealed good experimental control, poor reporting standards and a lack of follow-up data. Conclusions: Mental ill health requires vigorous treatment, yet the current evidence base is too limited to identify with precision effective treatments specifically for children or adults with severe and profound intellectual disabilities. Clinicians therefore must work on the basis of general population evidence, while researchers work to generate more precise evidence for people with severe and profound intellectual disabilities.
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Psychological interventions for adoptive parents: a systematic reviewA systematic review methodology was used to evaluate research regarding psychological interventions for adoptive parents. The effectiveness of the diverse intervention models scrutinised was found to be mixed with regard to a range of parent and child outcomes. When service user feedback was sought, psychological interventions were found to be acceptable to adoptive parents. Overall, findings were weakened by multiple sources of potential bias in the studies reviewed. Further research is needed, with particular attention to the method, site and timing of outcome measurement, before firm clinical recommendations can be made regarding the relative benefit of specific models of psychological intervention for adoptive parents. Implications for future research are discussed with reference to the unique contextual challenges of conducting clinical studies with adoptive families.
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What are the attitudes toward patients with substance use disorders (SUD) among medical students in the UK: a systematic reviewBackground Patients accessing treatment for substance use disorders (SUD) are often met with negative attitudes from healthcare professionals. Identifying how future doctors perceive these patients is central to tackling stigmatized attitudes, which deter patients from utilizing services. This systematic review explores UK medical students’ prevailing attitudes toward SUD patients. Methods This PROSPERO-registered review is guided by the PRISMA checklist. Database and citation searches identified 1688 papers for screening, of which seven met the inclusion criteria and were quality assessed, extracted and synthesized. Results We found some students held negative attitudes, assigning SUD patients blame for their conditions and considering them more dangerous than other patients. Students also lacked confidence in addressing these patients’ needs. They felt SUD teaching was low priority on their curricula, despite identifying doctors as responsible for overall SUD management. Progression through training appeared to correlate with improved attitudes within the included studies’ limitations, and diverse methods such as expert patients further enhanced student perceptions and knowledge. Conclusion Stigmatizing views of SUD patients remain present among UK medical students. Time and resources allocated to SUD education should better reflect the public health challenge it represents. Further work is needed to explore the effectiveness of stigma-reducing interventions.
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(Overcoming) attacks on thinking: the importance of psychoanalytic thinking in surviving systemic fragmentation of the public mental health sectorIn the last 15 years, the public mental health sector has been subject to two big policy shifts that have impacted the ability of Community Mental Health Teams (CMHTs) and Specialist Child and Adolescent Mental Health Service (CAMHS) clinics to deliver therapeutic services. This paper discusses the impact of the Improving Access to Psychological Therapies (IAPT) policy and the Health and Social Care Act (2012) on these services and the various barriers to effective treatment that they have created. The author then proposes that, as psychoanalytic psychotherapists, with our particular awareness of unconscious and group processes, we are well-placed to support multidisciplinary colleagues in overcoming feelings of hopelessness, anxiety and impotence that these policy shifts create and takes inspiration from potentially analogous situations with patients as a method to approaching the systemic aspects of our work.
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What influences social outcomes among offenders with personality disorder: A systematic reviewBackground Personality disorder is highly prevalent in offender populations and is associated with poor health, criminal justice, and social outcomes. Research has been conducted into factors that influence offending and health, but, in order to improve (re)habilitation, service providers must also be able to identify the variables associated with social outcomes and the mechanisms by which they operate. Aim To establish what is known about what influences social outcomes among offenders with personality disorder. Method A systematic review was completed using Cochrane methods, expanded to include nonrandomised trials. Anticipated high heterogeneity informed a narrative synthesis. Results Three studies met inclusion criteria. Two were qualitative studies including only 13 cases between them. All studies were low quality. Conclusions There is insufficient evidence to determine what influences good social outcomes among offenders with personality disorder. Research is required to identify associated variables, to inform the development of effective interventions.
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A systematic review of the literature on ethical aspects of transitional care between child- and adult-orientated health services.Background Healthcare policy and academic literature have promoted improving the transitional care of young people leaving child and adolescent mental health services (CAMHS). Despite the availability of guidance on good practice, there seems to be no readily accessible, coherent ethical analysis of transition. The ethical principles of non-maleficence, beneficence, justice and respect for autonomy can be used to justify the need for further enquiry into the ethical pros and cons of this drive to improve transitional care. The objective of this systematic review was therefore to systematically search for existing ethical literature on child- to adult-orientated health service transitions and to critically appraise and collate the literature, whether empirical or normative. Methods A wide range of bioethics, biomedical and legal databases, grey literature and bioethics journals were searched. Ancestral and forward searches of identified papers were undertaken. Key words related to transition, adolescence and young adulthood, ethics, law and health. The timeframe was January 2000 to at least March 2016. Titles, abstracts and, where necessary, full articles were screened and duplicates removed. All included articles were critically appraised and a narrative synthesis produced. Results Eighty two thousand four hundred eighty one titles were screened, from which 96 abstracts were checked. Forty seven full documents were scrutinised, leading to inclusion of two papers. Ancestral and forward searches yielded four further articles. In total, one commentary, three qualitative empirical studies and two clinical ethics papers were found. All focused on young people with complex care needs and disabilities. The three empirical papers had methodological flaws. The two ethical papers were written from a clinical ethics context rather than using a bioethical format. No literature identified specifically addressed the ethical challenges of balancing the delivery of transitional care to those who need it and the risk of pathologizing transient and self-limited distress and dysfunction, which may be normal during adolescence. Conclusions There is very little research on ethical aspects of transitional care. Most existing studies come from services for young people with complex care needs and disabilities. There is much scope for improvement in the amount and quality of empirical research and ethical analysis in this area.
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Self-Control, Plan Quality, and Digital Delivery of Action Planning for Condom and Contraceptive Pill Use of 14–24-Year-Olds: Findings from a Clinic-Based Online Pilot Randomised Controlled TrialBackground: Inconsistent use of the contraceptive pill and condoms contributes significantly to poor sexual health outcomes for young people. There is evidence that action planning interventions may improve pill and condom use, but this approach is not systematically used in sexual healthcare. This study is the first to assess acceptability and feasibility of evaluating a digital intervention to support action plan formation for three sexual health behaviours with clinic attendees. It also considered the role of trait self-control and whether the intervention supported production of quality plans. Methods: Eighty-eight integrated sexual health clinic attendees aged 14-24 years (M = 20.27 years) were recruited to a pilot randomised controlled trial (RCT). Of these, 67 also completed three-month follow-up. Measures included self-reported contraceptive or condom "mishaps", theory of planned behaviour variables, and a measure of self-control. Results: Descriptive analyses supported study acceptability and feasibility. The intervention supported pill and condom users to produce quality plans, though potential improvements were identified. Bivariate correlations suggested that high levels of trait self-control may negatively influence plan quality. Data suggest that the intervention may reduce pill or condom "mishaps". Conclusions: A future full RCT is likely feasible and brief digital action planning interventions may usefully be incorporated within sexual healthcare.
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A realist approach to the evaluation of complex mental health interventionsConventional 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.
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A systematic review of co-responder models of police mental health ‘street’ triageBackground Police mental health street triage is an increasingly common intervention when dealing with police incidents in which there is a suspected mental health component. We conducted a systematic review of street triage interventions with three aims. First, to identify papers reporting on models of co-response police mental health street triage. Second, to identify the characteristics of service users who come in to contact with these triage services. Third, to evaluate the effectiveness of co-response triage services. Methods We conducted a systematic review. We searched the following databases: Ovid MEDLINE, Embase, PsycINFO, EBSCO CINAHL, Scopus, Thompson Reuters Web of Science Core Collection, The Cochrane Library, ProQuest National Criminal Justice Reference Service Abstracts, ProQuest Dissertations & Theses, EThoS, and OpenGrey. We searched reference and citation lists. We also searched for other grey literature through Google, screening the first 100 PDFs of each of our search terms. We performed a narrative synthesis of our results. Results Our search identified 11,553 studies. After screening, 26 were eligible. Over two-thirds (69%) had been published within the last 3 years. We did not identify any randomised control trials. Results indicated that street triage might reduce the number of people taken to a place of safety under S136 of the Mental Health Act where that power exists, or reduce the use of police custody in other jurisdictions. Conclusions There remains a lack of evidence to evaluate the effectiveness of street triage and the characteristics, experience, and outcomes of service users. There is also wide variation in the implementation of the co-response model, with differences in hours of operation, staffing, and incident response.
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Use of a proforma to aid in reducing coercion into informal admission for acute adult psychiatric inpatients in the U.K.Background People with acute psychiatric illness may be at risk of coercion into informal admission. A lack of capacity assessment (CA) and provision of adequate information (PAI) for informal patients may constitute a risk of coercive admitting practice, resulting in increased use of the mental health act (MHA) in the days following admission. We developed and tested a proforma to aid in ensuring CA and PAI for informal admissions. Method A pilot case-study was conducted in 2015 at a U.K. NHS trust (n = 50), analysing the prevalence of CA & PAI for adult psychiatric inpatient admissions, alongside the prevalence of MHA use in the next 72 h. Case-note audits were completed in 2016 & 2017 (n = 100 each), to assess the impact of the proforma in improving documented CA & PAI, alongside the prevalence of MHA use in the next 72 h. We tested for any demographic associations with CA & PAI using logistic regression. Results CA improved from 39% (2015) to 60% (2017). PAI improved from 9% (2015) to 45% (2017). Use of the MHA in the 72 h following admission fell from 32% (2015) to 7% (2017). Most informal admissions detained within 72 h had no record of CA & PAI. People under the age of 26 years were significantly less likely to have documented CA & PAI. Implications Use of the proforma was successful in improving CA & PAI in a U.K. population. Further improvements could be made. Future research should seek to further examine demographic differences in informal coercion.
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QI 104 Implementation of MOSAIC (Multi-disciplinary One Stop Assessment and Intervention Clinic) within a Home Treatment TeamAim: To reduce the: 1.Proportion of people referred to the Home Treatment Team (HTT) following their initial assessment with the Mental Health Access Hub (MHAH) by 10% 2.Length of stay (LoS) for those patients referred to the Home Treatment Team (90% referrals <42 day length of stay) 3.Waiting time for an initial medical review following referral to the Home Treatment Team by 50%. The initial assessment of patients referred to the HTT should include multi-disciplinary team (MDT) assessment of needs, but involving different professionals often occurs over days to weeks. MOSAIC was introduced as a one stop MDT clinic set up to review newly referred patients who required an urgent assessment. Prior to MOSAIC patients were seen by the MHAH where there was no immediate access to an MDT. The assessment was undertaken by one clinician who determined if the patient required the HTT or another community team. This could lead to delays in the assessment process. Tools Used: Clinical Audit; SPC Charts; Patient/Survey Feedback. Aim Target Achieved Reduce number patients referred to HTT 10% 34% Reduction in LoS (to <42 days) 90% 86% Reduce time to initial medical review 50% 95% Project Impact: Aim - Reduce number of patients referred to HTT - Target 10% - Achieved 34%; Aim - Reduction in LoS (to <42 days) - Target 90% - Achieved 86%; Aim - Reduce time to initial medical review - Target 50% - Achieved 95%.
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QI 152 To Improve Patient Safety for Those at Risk of Choking in an Inpatient SettingAim: To Increase Awareness and Increase Referrals by 30% for Patients at Risk Of Choking Within Learning Disabilities & Autism & Mental Health Inpatient Services. This project has been run jointly across MH and LD&A inpatient services. Across the services there were only small numbers of referrals being received, these were often following very severe choking events. Previous attempts to implement a referral process had been been unsuccessful. The processes, referral information, national guidance etc were reviewed to understand the current situation. Based on this a screening tool and referral process along with awareness training were developed and tested on one ward and gradually rolled out across other wards as the tool and process was adapted. Awareness training has been rolled out across the mental health wards and as part of staff induction in Learning Disabilities and Autism. Tools Used: Driver Diagrams - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; SPC Charts - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf; PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf. Project Impact: Standardised screening tool for assessing risk and making referrals to Dysphagia Service. Monthly report to Dysphagia Service re: choking incidents. Increase in referral rate for dysphagia assessment. Increased staff awareness across inpatient services. Screening being embedded into MH & LD&A admission pathway. Screening being completed as standard within Health Action Plan in LD&A. Facilities awareness and food Modification training.
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Architecture and functioning of child and adolescent mental health services : a 28-country survey in EuropeThe WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed.
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QI 1263 Improving the Delirium Pathway at an Acute Hospital: GEH AMHATAim: Reduce the percentage of referrals to AMHAT for delirium from 35% to <10% by 31st December 2023. AMHAT at CWPT provides liaison work to UHCW, SWFT and GEH and receives referrals from each of these areas. Delirium is a medical condition which needs to be treated medically by professionals at acute hospitals. Patients with delirium should not be referred to AMHAT. It was noted by the GEH AMHAT team that a relatively large number of referrals from GEH wards had delirium as an outcome. These inappropriate referrals delayed patient management as patients were waiting for a review by AMHAT when they could have received medical care on the ward. These cases also utilised AMHAT time that could have been directed to prioritise more appropriate referrals and tasks. Tools Used: PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; Sustainability Tool - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-sustainability-model.pdf. Project Impact: There was a reduction in the number of referrals identified as delirium from 44 (35%) in June, July and August to only 8 (6%) in October, November and December. Each inappropriate referral would take an AMHAT clinician an average of 1 hour, this equates to a potential saving of 36 hours of clinical time over October, November and December which could be utilised to reduce waiting times for other patients. Patients receiving the appropriate care on the ward rather than waiting for AMHAT review means their length of stay is reduced - a potential reduction of 72 bed days. Early management of patients as per the Delirium Pathway has increased leading to better patient experience. Right care at the right time and earlier discharges. Better prioritisation and use of clinician time for both Acute hospital staff and AMHAT.
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Assessing the second-hand effects of a new no-smoking policy in an acute mental health trustAims and method To examine whether a new no-smoking policy in an in-patient mental health setting had any effects outside of smoking cessation. Our hypothesis stated that a forced smoking ban for in-patients may result in an increased susceptibility for clinical incidents, aggression and lower admission rates. All patients admitted to adult in-patient mental health services in Coventry and Warwickshire Partnership NHS Trust were included in the analysis. Data 6 months post-implementation of the smoking policy (1 July 2015 to 1 January 2016) were compared with the same period 1 year prior (1 July 2014 to 1 January 2015). Patient demographics, admission rates, ward occupancy, average lengths of stay, numbers of reported incidents and use of the Mental Health Act 1983 (MHA) were compared. Results We analysed 4223 admissions. We found a significantly increased number of admissions under the MHA (P = 0.007), a significantly greater number of reported smoking-related incidents (P < 0.001) and aggression-related incidents in the psychiatric intensive care unit (P < 0.001). However, we found no significant difference in capacity of in-patient wards (P = 0.39), admission length (P = 0.34) or total aggression-related incidents (P = 0.86). Clinical implications Although further comparisons over longer time periods are necessary, our results suggest that enforced smoking cessation on acutely unwell psychiatric patients admitted to the most restricted environments may have some negative effects. Nicotine replacement therapy should be offered to all patients to minimise the risk of clinical incident.
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QI 73 Reducing Restrictive Practice - November 2018 to April 2020Aim: To reduce the overall use of restrictive practice by 30% by April 2020. This project was run by RCPSYCH and included 40 wards across the country, focussing on Improving Mental Health Safety. Rowans was identified as a target ward to be included and was supported by a QI Coach from the RCPSYCH. We created a Driver Diagram to help focus change ideas into themes Leadership and Learning Culture, Co-Production, Environment, Prevention and Predication and Person Centred Care. We identified how we would collect data and display progress, using a safety cross and incident reporting data, and we used a collaborative approach, including patient involvement, to generate ideas to implement and test using the PDSA cycle. Tools Used: Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf. PDSA Cycle - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf. Statistical Process Control (SPC) chart - www.england.nhs.uk/statistical-process-control-tool. Project Impact: Staff and patients identified communication and trust was improved. The staff team felt more motivated. The team feel less stressed and able to focus on being creative with the client group and developing interpersonal relationships. The patients felt that the interventions have been empowering. Overall data showed a 55% reduction. Physical restraint saw a 57% reduction and rapid tranquilisation became in line with normal variation.
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QI 140 To reduce the length of stay within the Crisis Home Treatment Team (CRHT) for Older AdultsAim: To reduce the length of stay within the Crisis Home Treatment Team (CRHT) to 42 days for 60% of Older Adults by September 2021. The age integrated CRHT caters for people aged 18 years and over. Clinical reviews within the team indicated inadequate risk assessments leading to ineffective management plans when dealing with older adult referrals. Informal discussion with staff revealed lack of experience and confidence leading to poor service delivery and impact on length of stay with the team. Key areas of focus 1.Recruit skilled professionals within Triage and Assessment. Team with older adult experience. 2. Develop older adult champions. 3. Develop link workers within IPUs who can work alongside the champions for seamless transfer of patients. Tools Used: Plan, Do, Study, Act (PDSA) Cycle which is a framework that helps you to test small changes. This is part of the Model for Improvement framework, which helps you to test out small changes and build on the learning from each cycle - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Driver Diagram which is a tool designed to show 'cause and effect' and can help you plan your improvement project - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf. Project Impact: Training : Feedback before and after related to confidence in dealing with older adult referrals. Overall, very positive feedback and request for more online resources related to social care and voluntary sector –which were sent to attendees. Referrals: There was a very marked reduction in the number of referrals received between the 2020 period and the 2021 period. Reduction occurred in referrals which then resulted in relatively short lengths of stay. 30.8% of the overall reduction of 318 referrals was in referrals that were discharged on the same day, and 84.3% of the reduction comes from referrals discharged within four days. The number of referrals discharged on the same day fell from 110 in 2020 to just 12 in 2021.
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QI 180 Implementing Behavioural Family Therapy (BFT) in the Perinatal Mental Health Team (PMHT)Perinatal Psychological therapies is part of the NHS England Long Term Plan (LTP). The national ambition is to expand access to evidence-based therapies within PMHT so that they also include parent > infant, couple and family interventions. A secondment post was introduced in the Trust’s PMHT to help achieve this aspect of the LTP to introduce and implement a ‘whole family’ approach utilising the BFT MERIDEN Programme which is already utilised in psychosis specific teams within CWPT (Early Intervention and Recovery). Tools used: Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; Stakeholder Analysis - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-stakeholder-analysis.pdf; Process Mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-mapping-the-process.pdf. Project Impact: The project has helped offer more support and resources for client’s carers and families and upskilled staff and increased their confidence of this patient cohort. The project benefitted the Trust by securing a cost saving of £1,150 by negotiating training costs with the training provider. Not only has the project given carers of patients more of a voice and support system, it has united the PMHT and supported integrated working. Next steps are; 1. Secure Develop leaflets and handouts to support programme delivery 2. Continue BFT supervision for the contracted year with MERIDEN 3. Continue to complete data template 4. Adapt process for other mental health services in the Trust
