RSS 1.0Mental Health and Behavioural Conditions: General and Other
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Working Diagnoses : a pilot studyAims: Mental Health and Neurodevelopment Resource Group (MHNRG) are planned to replace Mental Health Clustering. However, they are broad diagnostic groupings which will potentially have limited benefit in relation to evaluating outcomes, health inequalities, pathways, and interventions. In addition to mandatory completion of MHNRG, local services have the option to collect additional categorical data which led to the introduction of Working Diagnoses. This is a pilot study to trial Working Diagnoses to test its functionality and feasibility. Method(s): The aim of the Working Diagnoses is to create an accessible form on the electronic patient record allowing assessors to select a list of up to four working diagnoses via a drop-down menu. Following consultation with clinicians from differing psychiatric specialities, a list of 53 separate working diagnoses were agreed upon which were individually mapped to their respective ICD-11 diagnostic codes and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) to make it future proof. The pilot was conducted within the local Crisis Resolution and Home Treatment and Primary Care Mental Health teams. A live and secure Microsoft Excel document with a list of the working diagnoses through a drop-down menu was created. Assessors consisting of both doctors of various grades and psychiatric nurses within the teams were briefed on the aims and objectives of the pilot study. At this stage, it is not intended for the diagnostic data to flow into the Mental Health Services Data Set (MHSDS). Result(s): 127 patients referred to the teams between November to December 2023 were included in the pilot study and allocated their working diagnosis; 66 received one diagnosis, 52 received two and 9 received three diagnoses and none received four. All presentations were able to be satisfactorily described by the Working Diagnoses options. The general feedback from assessors who participated in the study reported that it was simple and easy to use despite having limited formal training. Conclusion(s): We believe that mental health services require granular details of a person's presentation if we are to effectively commission, transform and manage our services. Though other options could be utilised, implementing a limited categorical diagnostic list appears to be an acceptable, effective, and efficient method of gathering the information that has been missing in mental health services locally. The next steps will be to trial this to other services within the wider trust.
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Venous Thromboembolism (VTE) risk assessment in acute inpatient mental health wards in Sherwood Oaks and Millbrook Unit (now Blossomwood Unit), Nottinghamshire Healthcare NHS Foundation TrustAims: To assess compliance with the trust policy and NICE guidelines on VTE risk assessment for new admissions into the acute psychiatric wards in Millbrook and Sherwood Oaks mental hospitals, Nottinghamshire NHS Foundation Trust. Method(s): A retrospective audit looked at case notes of patients aged 20-80 years, admitted within a 2 weeks period across 8 wards in April 2023. This was re-audited in April 2024 after all recommendations were actioned. Infornation was collated and manually analysed. Data collected included but not exclusive to date of admission, date VTE risk assessment was done and the level of VTE risk identified. These were compared with the standard criteria which were the trust policy 02.21 - 'Patients who are admitted should have VTE risk assessment within 24 hours of admission' and the NICE guidelines NG(82) 2019 - 'Assess all acute psychiatric patients to identify their risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the first consultant review'. Result(s): The first cycle found that only 69.3% of the patients admitted were assessed on admission (with 50% assessed within 24 hours of admission) whereas 30.7% were not assessed throughout the duration of their admission. The second audit cycle showed remarkable improvements. 80.5% were assessed for VTE risk (63.9% within 24 hours of admission) whereas 19.5% were not assessed. The level of risk was categorized into low, moderate and high risk using Well's scoring system. 69% of patients who were assessed in the first cycle, had low risk but risk of 31% of the cohort of patients audited were unknown because they were not assessed. In the second cycle,80.5% had low risk whereas 19.5% of the patients fell under the unknown category due to not having been assessed. Conclusion(s): The importance of VTE risk assessment in acute inpatient wards can never be overemphasized. Studies show that psychiatric inpatients are likely to be at an increased risk of VTE due to - use of psychotropic agents, reduced mobility, dehydration as a result of self-neglect or suicidal attempts, prolonged restraints, sedation, co-morbid physical health problems etc. There are still lapses in our patient management that need to be considered in order to provide an outstanding patient care and safety.
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Investigating adherence to the 2022 NICE vitamin D management guidelines on MHSOP (Mental Health Services for Older People) wardsAims: Vitamin D deficiency is a widespread problem in older people with reduced ability for production, along with risk factors such as indoor living. Improving adherence to the vitamin D guidelines is a simple and cost-effective method of potentially reducing falls, morbidity and mortality in older patients with risk factors. Aim is to assess whether vitamin D deficiency is identified and managed appropriately according to the 2022 NICE vitamin D guidelines. Standard: 1. All patients to have vitamin D level tested on admission. 2. All patients with vitamin D level of 50 and below to be prescribed vitamin D as per guidelines. 3. If calcium deficiency co-exists with vitamin D deficiency, patients to be prescribed replacements for both as per guidelines. 4. All patients to be referred for specialist services if vitamin D deficiency presents with the following: eGFR <30, hypercalcaemia, or granulomatous conditions. Method(s): The audit was registered with the Trust following discussion with the ward managers and consultants. All inpatients on two MHSOP wards on the day of data collection were included. Using an audit questionnaire, retrospective data was collected from electronic patient notes, paper drug charts and electronic blood reporting system. Data was analysed on Excel. The re-audit occurred six months later following intervention. Interventions following the initial audit involved designing a vitamin D awareness poster for the wards, meetings with the ward pharmacist and presentation at the local MHSOP clinical effectiveness meeting to raise awareness. Result(s): First cycle: 34 patients were included. 30 out of 34 (88%) patients had their vitamin D levels tested on admission or had a recent level. Out of the 30 patients who had recent vitamin D levels on record, 15 patients had adequate vitamin D levels, seven had insufficient levels, and eight had deficient levels. Out of the 15 patients who had insufficient or deficient levels, nine patients (60%) were prescribed vitamin D. One patient who required specialist services did not get referred. Second cycle: 33 patients were included. 31 patients out of 33 (94%) had vitamin D testing on admission. Out of the 31 patients, 12 patients had deficient or insufficient vitamin D levels requiring prescription. Nine out of these 12 patients (75%) were prescribed vitamin D. Conclusion(s): Following simple interventions to raise awareness, the re-audit results showed improvements in vitamin D testing on admission as well as improved management. Ongoing communication with pharmacists and rotating resident doctors is required to sustain awareness and improve adherence.
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In adults with severe psychiatric disorders, how does the option of assisted dying compared with standard psychiatric care or palliative care impact patient autonomy, quality of life, and ethical considerations : a comprehensive meta reviewAims: This systematic review sought to compare the effect of assisted dying options on self-determination, patients' quality of life, and specific/ethical concerns including suicidality for adults with severe psychiatric disorders and psychiatric or palliative care. Method(s): The data sources gathered for this review were PubMed, EMBASE, CINAHL and Cochrane databases. The search terms consisted of different forms of assisted dying to which various forms of psychiatric and mental health-related terms were added. The papers were restricted to systematic reviews and meta-analyses as these give high-quality evidence. Out of 343 studies after strict criteria such as ROBINS 1, ROB2 and AMSTAR, only 3 studies qualified for the review. The review centred on adults with severe psychiatric disorders, specifically patients with eating disorders who had assisted dying between 2012 and 2024. Result(s): The present review estimated that at least 60 individuals with eating disorders who received assisted dying between 2012 and 2024 were reported across 10 peer-reviewed studies and 20 government reports. Clinical rationales for granting assisted dying requests fall into three main domains: non-treatability, prognosis and request of the patient. Most of the reports highlighted two aspects: that the patients had a terminal or untreatable disease, as well as sufficient decision-making abilities. Still, only a few reports were available for the government and many of them failed to provide adequate data on psychiatric conditions. The review showed that there were significant gaps in reporting assisted deaths for psychiatric patients and ministers questioned accountability and patient safety. Some clinical justifications were void of rigour or evidence indicating the plausibility of the irremediability or lack of decisional capacity in psychiatric relatedness. Conclusion(s): The findings of this systematic review can be concluded as indicating the lack of procedural clarity and strengthened precaution measures for assisted dying in the field of psychiatry. The results imply the applicability of the ethical principles as well as clinical considerations call for incremental case-by-case analyses. The study should be extended to propose improved reporting systems for assisted dying and to confirm clinical justification for several patients who received help in psychiatric practices, with the consideration of patient rights and safety.
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The effect of the ketogenic diet on aggression and violence in patients with severe mental illness : a systematic reviewAims: The aim of this systematic review was to explore the existing literature on the impact of the ketogenic diet on aggressive and violent behaviour in patients with serious mental illness and the potential mechanisms involved, with the hypothesis that the ketogenic diet can reduce aggression and violence in this patient population. The ketogenic diet has proven to be useful as a therapeutic to reduce some clinical symptoms of certain neurological and psychiatric conditions, so this review was interested to determine if there were any correlations in impacts on behaviour in similar patient populations. Method(s): Following the PRISMA guidelines, a systematic review was conducted of the bibliographic databases MEDLINE, PsycINFO, Scopus, Web of Science, Cochrane Library, PubMed and Open Grey. The sources retrieved were narrowed down using specific inclusion and exclusion criteria and quality appraisal of the relevant sources was carried out using the Joanna Briggs Institute critical appraisal tools. Result(s): Of the 32 sources included in the final review, 26 of these, when linked together by association, supported the concept of the ketogenic diet reducing aggression either directly or indirectly via metabolites upon which the ketogenic diet can impact. Increased beta- hydroxybutyrate, gamma-aminobutyric acid and brain-derived neurotrophic factor were all observed when following the ketogenic diet and were, in most cases, associated with reduced aggression. Conclusion(s): Despite the limited literature available on the topic, the majority of the relevant sources supported the notion that the ketogenic diet could generally reduce aggression, an observation that could often be replicated in psychiatric settings. The conclusions made in this review were mostly formed by making associations between the available sources, so future research would need to be conducted with the specific focus of observing the impacts of the ketogenic diet on behaviour in psychiatric settings. Randomised controlled trials should be conducted in both inpatient and outpatient settings to enable further systematic reviews and metaanalyses to evaluate the ketogenic diet's potential for use as a nonpharmacological therapeutic in prescribing and patient care.
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Co-producing a survey on prospective acceptability of neuromodulation for mental health conditions with lived experience expertsAims: Non-invasive brain stimulation ("neuromodulation") techniques, including transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES), are used to modulate brain excitability and connectivity. TMS is approved for treating depression in the United Kingdom and preliminary evidence suggests that combining TMS and TES may enhance therapeutic effects. While neuromodulation is generally well-tolerated in research settings, its acceptability among the broader patient population remains unclear due to limited exposure, awareness, and information accessibility. Understanding prospective acceptability, defined as the perceived appropriateness of an intervention before its application, is crucial for improving treatment uptake and addressing concerns about safety and feasibility. We aimed to coproduce a survey with lived experience experts to assess the acceptability of individual and combined neuromodulation techniques among potential service users. Method(s): The study was co-developed with our Neuromodulation Experts-by-experience Advisory patient and public involvement (PPI) group. We underwent three rounds of iterative feedback to refine the survey focus, structure, and questions. A scoping review of existing literature on prospective acceptability of neuromodulation techniques informed the content, alongside the Theoretical Framework of Acceptability. Given the novelty of combined (TMS +TES) neuromodulation, no prior informational materials exist. PPI members advised it was critical to produce accompanying videos and leaflets to briefly illustrate the different neuromodulation techniques. The video scripts and leaflet content were produced in collaboration with three PPI members who tried the neuromodulation techniques, to avoid rehearsed scripts and ensure honest reviews of the techniques. Result(s): The final survey version was adapted to maximise clarity of questions, engagement, and completion rates. The survey incorporated questions on awareness, perceived effectiveness, ethical considerations, and practical burden of different neuromodulation techniques. Online and paper versions of the survey were created to ensure accessibility. We successfully produced three information videos within 90-second target duration featuring PPI members and lead researchers. We developed a supplementary infographic leaflet for enhanced comprehension and accessibility. Conclusion(s): Engaging stakeholders through PPI was instrumental in developing the survey to ensure accessibility and relevance for diverse participants with lived experience of mental health conditions. End-user involvement in the design process improved survey comprehensibility, highlighting the importance of coproduction in developing effective research tools. Findings from this survey will provide insights into the acceptability of novel neuromodulation techniques, ultimately informing future clinical implementation and patient-centred research strategies.
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A case of depersonalization-derealization disorderAims: Background: Depersonalization-derealization disorder (DPDR), classified under ICD-11 code 6B66, involves persistent or recurrent experiences of depersonalization, derealization, or both. Depersonalization refers to a sense of detachment from one's thoughts, emotions, or body, whereas derealization involves perceiving the external world as unreal or distorted. These symptoms cause significant distress or impairment, are not attributable to other mental disorders, substance use, or medical conditions, and occur while reality testing remains intact. Method(s): Case Report. An 18-year-old female A-level student presented with a two-year history of frequent episodes in which her surroundings, including people and familiar environments, felt unreal. These episodes varied in duration and were highly distressing, particularly during emotional extremes such as heightened happiness or stress. Symptoms were most pronounced in the evenings or when she was unoccupied, leading to emotional breakdowns. Despite these experiences, she remained aware of her own reality, with disturbances centred on external perceptions. Her symptoms began following a nine-month psychiatric hospitalization. Prior to admission, she experienced unexplained gastrointestinal symptoms, and in the absence of an identifiable physical cause, she was diagnosed with conversion disorder. The hospitalization was distressing due to frequent invasive procedures, a perceived sense of blame for her condition, and feelings of entrapment. She subsequently developed post-traumatic stress disorder (PTSD), characterized by flashbacks, nightmares, and avoidance of medical settings. However, DPDR symptoms persisted outside of PTSD-related re-experiencing episodes, causing ongoing distress and impairment. Result(s): Discussion: This case highlights the complex interplay between DPDR and PTSD, particularly following medical trauma. While dissociative symptoms frequently occur in PTSD, ICD-11 differentiates DPDR as a distinct disorder when symptoms persist beyond re-experiencing episodes. In this case, the patient's prolonged hospitalization, combined with perceived invalidation and invasive interventions, likely contributed to the development of DPDR as a maladaptive dissociative response. The exacerbation of symptoms during emotional extremes aligns with research indicating that dissociation may function as an affect regulation mechanism. Trauma-related dissociation has been linked to disruptions in emotional processing, potentially interfering with adaptive coping strategies. This underscores the importance of targeted psychological interventions to reduce distress and improve functional outcomes. Conclusion(s): A trauma-informed, multidisciplinary approach is essential in managing this patient's complex presentation. Psychological interventions such as EMDR or trauma-focused CBT should be integrated with ongoing medical care to address both dissociative symptoms and physical health concerns. Collaborative management between psychiatric and medical teams will be crucial in promoting long-term recovery, enhancing her psychological resilience, and improving overall quality of life.
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An audit of metabolic monitoring compliance in patients initiated on antipsychotics across general adult wards in the East MidlandsAims: The Lester Tool mandates baseline monitoring parameters for patients starting new antipsychotics or having their current antipsychotic regimen changed. These parameters include blood pressure, haemoglobin A1c (HbA1c)/fasting plasma glucose, lipids, lifestyle review, waist circumference, and weight, along with weekly weight monitoring for six weeks consecutively. This audit was initiated in response to concerns about rapid weight gain observed in many patients after starting certain antipsychotics. It aims to assess compliance with the Lester Tool to address the potential risks of metabolic syndrome in these patients. The audit seeks to understand the pattern of antipsychotic prescriptions as a secondary objective. Method(s): The audit was registered and ethically approved by the local research and audit department. A retrospective review of electronic health records and medication charts was conducted for 38 patients residing in two male and two female inpatient wards in the East Midlands between 17 June 2024 and 26 June 2024. Baseline parameters were audited to determine if they were measured within one week of antipsychotic initiation, and weekly weight checks thereafter. Waist circumference measurement at baseline was excluded due to concerns about its potential impact on patient self-esteem. Result(s): Among baseline monitoring parameters, blood pressure had the highest compliance at 89.5%, followed by HbA1c/glucose (65.8%), lipids (57.9%), lifestyle review (55.3%), and weight monitoring (36.8%). Weekly weight follow-up compliance was low, with only 5.9% of patients meeting 100% compliance, and 41.2% of patients having no documented weight follow-up within six weeks. Non-compliance reasons were poorly documented. Risperidone was the most prescribed antipsychotic (N=9), followed by olanzapine (N=8), zuclopenthixol (N=7), and quetiapine (N=6). Olanzapine and risperidone were most frequently initiated in male wards, while zuclopenthixol and quetiapine were more common in female wards. Conclusion(s): The audit identified significant gaps in compliance with the Lester Tool, which poses a risk to patients' physical health due to the metabolic side effects of antipsychotic medications. The findings underscore the need for better documentation and communication regarding baseline and follow-up measures. Recommendations include increasing awareness of baseline blood requirements during admission, improving electronic health record functions (e.g. alerts for weekly weight checks and a drop-down to document weight check refusals), and enhancing coordination in monitoring patient weight following planned home leaves. A re-audit is ideal once the recommendations have been implemented.
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Audit of melatonin use across child and adolescent mental health services (CAMHS) in LincolnshireAims: To establish baseline data on melatonin use. To compare the patterns of use with national guidelines. To make recommendations to the teams. Method(s): A retrospective audit of patient records under the CAMHS services in Lincolnshire was undertaken to identify patients on melatonin as of June 2024. Data was collected from medical records between June and July 2024. Patients under 19 years and prescribed melatonin were included. Patients previously on melatonin but discontinued by June 2024 were excluded. This audit was inspired by the POMH melatonin audit. Result(s): 54 patients were identified, 23 males and 31 females. About half of the patients had been on melatonin for over one year (n=25). Autism/autistic spectrum disorder was the most common diagnosis/comorbidity - 36 patients, 29 patients had an anxiety disorder, 21 patients had diagnosed/comorbid hyperkinetic disorders, 12 patients had mood disorders while 14 patients did not have a diagnosed neurodevelopmental disorder. In 84.6% of prescriptions, evidence-based non-pharmacological measures were tried first. The target symptom(s) for melatonin treatment was clear in 55.6% of cases. Sleep latency was the most common target, followed by reducing night-time awakening. Licensed melatonin preparation was used in 46.3% of prescriptions. The preparation was however not clearly documented in most of the cases. (Licensed use covers insomnia with autism spectrum disorder (Slenyto), insomnia with Smith-Magenis syndrome (Slenyto), insomnia associated with behavioural disorders in children and adolescents (Adaflex)). 86.7% of prescriptions were reviewed for efficacy within 3 months while tolerability (side effects) was reviewed in 46.7%. The need for continuing melatonin treatment was reviewed annually in 80.8% of cases while tolerability was reviewed in 30.8%. Conclusion(s): The audit revealed high rates of prescription in certain areas of the county, it also showed that documentation of indication and target symptoms was not always available, similarly review of tolerability (side effects) was not always available. The findings were presented to the CAMHS consultants. The high rates were thought to be related to shift in practice over time, perhaps due to consultants shortage. Documentation of efficacy was more often done than review of tolerability. One reason for this could be that melatonin was being monitored by the community paediatrics team or the GP. The need for clear documentation can therefore not be overemphasized. The audit did not consider those who were able to stop melatonin. This could be useful to support patients.
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Reflections on using the power threat meaning framework on an acute inpatient male wardThis reflective piece examines the authors’ experiences of introducing the Power Threat Meaning Framework on a men’s acute inpatient ward aiming to promote more collaborative psychologically informed approaches to understanding distress Working within a system traditionally dominated by the medical model the authors consider how the Ptmf offered a shared language for understanding distress in ways that emphasised personal meaning power dynamics contextual factors. The paper reflects on the, opportunities challenges of applying the Ptmf in this setting, including tensions between psychological diagnostic, approaches the importance of relationship-building, curiosity cultural sensitivity. The authors also describe how the, Ptmf can inform trauma-aware practices help shift team discussions around, formulation care planning. The paper concludes with thoughts on the implications for clinical work, team collaboration broader application of the, PTMF.
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Living with mental health issues: citizen science project on self-management strategiesPeople living with mental health issues use a range of self-management strategies. Most strategy recommendations have been developed by clinicians and researchers, so they may not reflect the full range of approaches used in practice. A citizen mental health science methodology can address this bias in strategy identification. We co-created a list of 77 pre-defined self-management strategies, and 1116 public contributors (n = 468 mental health service users, n = 497 lived experience not using services, n = 151 no lived experience) living in the United Kingdom completed an online survey identifying their use of each strategy, and identifying extra strategies. A wide range of pre-defined strategies were used by contributors, with differences in usage patterns identified between the three groups. 401 distinct extra strategies were identified. The active use of avoidance as a self-management strategy was more common than anticipated, including avoiding alcohol, social media, thinking about problems, other people, and mental health services.
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An Investigation of the effects of α- and β-Frequency neural entrainment using tACS on phase-aligned TMS-Evoked corticospinal excitabilityPURPOSE: Deep brain stimulation (DBS) is an effective treatment for many brain disorders (e.g., Parkinson's disease), has a favorable adverse effect profile, and can be particularly effective for individuals with treatment-resistant symptoms. DBS is, however, inaccessible for most individuals, is extremely expensive, and is not considered suitable for children and adolescents. For these reasons, noninvasive alternatives to DBS, such as transcranial magnetic stimulation (TMS), are increasingly being sought to treat brain health conditions. Unfortunately, current TMS approaches exhibit large intra- and inter-subject variability in their efficacy, which limits their use clinically. One likely reason for this is that TMS is invariably delivered without reference to ongoing brain activity (i.e., open loop). METHODS: We propose that the efficacy of stimulation might be improved, and the variability of its effects reduced, if stimulation could be synchronized with ongoing brain activity. To investigate this, we used transcranial alternating current stimulation (tACS) to induce entrainment of brain activity at two frequencies (α = 10 Hz and β = 20 Hz), and we delivered single-pulse TMS that was temporally aligned with the phase of each tACS oscillation. To investigate the effects of tACS-phase-aligned TMS, we measured motor-evoked potentials (MEPs). FINDINGS: Our findings confirm that for α- and β-tACS, both corticospinal excitability and inter-trial variability varied as a function of tACS phase. Importantly, however, the tACS phase angle that produced maximum TMS-evoked excitability was different for α- and β-tACS, coinciding with the negative peak (trough) for α-tACS and the positive peak (peak) for β-tACS. CONCLUSION: These findings confirm that aligning noninvasive brain stimulation to ongoing brain activity may increase the efficacy of TMS and reduce the variability of its effects. However, our results illustrate that the optimal phase of the tACS cycle at which to deliver TMS may vary for different tACS frequencies.
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Enhancing cross-cultural applicability in recovery colleges : a global Delphi study protocolBACKGROUND: Recovery Colleges (RCs) offer an innovative model of mental health support that blends co-production with adult learning to promote personal recovery and social inclusion. While evidence supports their effectiveness, most RC research and practice have been developed in Western contexts, raising concerns about cross-cultural applicability. The RECOLLECT Change Model (RCM) and RECOLLECT Fidelity Measure (RFM) were developed in England to characterise RC mechanisms and assess fidelity. Our previous studies have identified cultural influences on the RC operational model, however how to address these influences remains unknown. Given the increasing global interest in RCs, the aims of this study are to (a) identify the level of cultural influence on the RCM mechanisms and RFM items, and (b) provide recommendations to inform cross-cultural applicability of RCM and RFM. METHODS: This global Delphi study follows Belton's six-step methodology and uses a decentring approach to cross-cultural research that seeks to extend the relevance of tools developed in a single culture to multiple cultural contexts. Experts will be recruited via the RECOLLECT International Research Consortium, covering 31 countries across six continents. We aim to recruit approximately 100 panellists with at least three years' RC experience. Data collection will occur via Microsoft Forms across iterative Delphi rounds. Panellists will rate the importance and cultural difficulty of RCM and RFM items, provide feedback on culturally aligned response types, and suggest revisions for improved cultural fit. Quantitative data will be analysed using non-parametric statistics and a collapsed three-point Likert scale to address cross-cultural response bias. Qualitative responses will be analysed using descriptive content analysis informed by Hofstede's cultural dimension theory. Member checking will be conducted after the final round to enhance trustworthiness. DISCUSSION: This study will identify which RCM and RFM components are cross-culturally applicable and which require adjustment, contributing to the balance between fidelity and fit in mental health approaches. By developing culturally informed recommendations, this study aims to expand the accessibility and relevance of RC frameworks across diverse settings. Findings will benefit RC practitioners, researchers, and policymakers seeking to improve service delivery and recovery outcomes in culturally meaningful ways.
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Barriers and facilitators to using standardised diagnostic assessments in child and adolescent mental health services : a qualitative process evaluation of the STADIA trialThe STADIA trial aimed to assess the effectiveness of a standardised diagnostic assessment tool (Development and Wellbeing Assessment, DAWBA) in aiding clinician-made diagnosis decisions in Child and Adolescent Mental Health Services (CAMHS). This study reports the qualitative process evaluation of the STADIA trial, which aimed to identify barriers and facilitators to using the online-completed DAWBA in CAMHS. Qualitative data were collected through 109 semi-structured interviews with young people, parents/carers, healthcare professionals and service commissioners/funders in 8 CAMHS sites across England. Deductive thematic analysis was guided by the domains of the Consolidated Framework for Implementation Research. Young people and parents/carers showed high levels of engagement with the DAWBA. They perceived a validation of symptoms from the generated DAWBA report, which they actively used as 'evidence' when seeking help from other services. Clinicians involved in determining referral acceptance/rejection decisions were positive about its use and saw benefits in aiding decision-making. In contrast, however, barriers to clinicians engaging with the DAWBA report during the assessment stage arose from limited awareness and accessibility to the report, a context of high workload and pressure, and general concerns about the value of a diagnosis. The DAWBA was not widely used by clinicians in the expected way to aid diagnostic decision-making. However, it may offer children and young people much-needed engagement during long waiting times for initial assessment in CAMHS. The DAWBA may be more acceptable to clinical teams in triaging referrals to help with timely decisions about the most suitable services.Trial registration ISRCTN15748675 (29/05/2019).
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Patient ethnicity and staff use of restraints and restrictive practice in inpatient psychiatric services : a systematic reviewRestrictive practices such as restraints, seclusion, and forced medication are only intended to be used when the threat is at a level whereby an individual is likely to inflict harm on themselves or another individual. Demographic variations, including ethnicity, may be associated with the use of these practices. However, there is no systematic review on patient ethnicity specifically. The review therefore aimed to establish whether a patient’s ethnic identity was associated with staff use of restrictive practices in inpatient psychiatric services. The systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Four databases were searched (PsycINFO, Medline, Embase, and CINAHL). Methodological quality was assessed using the Critical Appraisal Skills Program Checklists. Fifteen studies met the inclusion criteria. A variety of ethnicities were identified within the studies. These were driven by the location of the study. Seclusion (14 studies), forced medication (4), and physical restraint (4) were explored. There were mixed findings, with ethnicity shown to predict restrictive practices in studies having larger participant numbers, longer follow-up periods and less methodological bias. It remains unclear whether ethnicity is a genuinely independent predictor of restraint and coercive practices or interacts with other risk factors. Staff working in inpatient settings should be aware of how unconscious biases might affect clinical practice. Recruiting a diverse workforce from minority ethnic groups into inpatient psychiatric services would be a positive step. However, support for these staff members is important, and all staff should be equipped to respond to ethnic diversity. Future research should explore beyond patient-level factors.
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Understanding patient pathways to Mother and Baby Units : a longitudinal retrospective service evaluation in the UKBACKGROUND: Mother and Baby Units are specialised psychiatric facilities for women during and after pregnancy. In the United Kingdom, efforts have been made to expand the Mother and Baby Unit availability and establish care guidelines. However, the accessibility of these services for ethnic minority women remains relatively unexplored despite well-documented disparities. AIMS: To explore patient pathways to Mother and Baby Units in three UK localities, with a focus on variations in pathways between services and among ethnic groups. METHODS: This is a three-site, longitudinal retrospective service evaluation conducted in Birmingham, London and Nottingham during a 12-month period (1 January-31 December 2019). Electronic records were accessed to extract data on the type of admission, the referral process and the type of pathway (simple or complex). The simple pathway entailed contact with one clinician/service prior to admission to the Mother and Baby Unit, while the complex pathway involved interactions with two or more clinicians/services before Mother and Baby Unit admission. Data were collected using the adapted World Health Organization Encounter form and were analysed using uni- and multivariable analyses. RESULTS: Electronic records from 198 patients were analysed, with participants distributed proportionally across three sites: Birmingham (n = 70, 35.4%), London (n = 62, 31.3%) and Nottingham (n = 66, 33.3%). All Mother and Baby Units were nationally commissioned and received referrals from across England. Most patients were in the post partum period, admitted for the first time through emergency, informal and complex pathways. The average length of admission was 6 weeks. Significant differences in admission characteristics were observed between services. Patients of Asian ethnicity had more emergency admissions compared to those of Black and White ethnicities. Ethnicity was the only significant factor associated with the simple/complex care pathway. After controlling for pathway-level and patient-level factors, Black patients were 6.24 times less likely to experience a complex care pathway than White patients. No evidence was found that patients from the Black ethnic background are detained more often than White patients. LIMITATIONS: The heterogeneity among categorised ethnic groups, data extracted solely from electronic records without validation through patients' personal accounts of their care pathways, unanalysed declined referrals and the utilisation of pre-COVID-19 pandemic data. The ethnic composition of the study sample matched that of the UK maternity population in the Nottingham subsample, but Black and Asian populations were over-represented in the Birmingham and London subsamples. CONCLUSION: The study provides valuable insights into patient journeys to Mother and Baby Units, highlighting significant differences between services. It also emphasises the role of ethnicity in care pathways. For example, Black patients were less likely to encounter more than two services before Mother and Baby Unit admission, suggesting either more direct access to specialist care or insufficient community-based interventions. This dual interpretation calls for future research to explore whether pathway differences among ethnic groups result from optimal clinical decision-making or gaps in care provision. FUTURE WORK: Should further examine the role of ethnicity in shaping care pathways; explore the link between care pathway types and treatment outcomes; investigate if simple or complex pathways result from optimal clinical decisions or gaps in the healthcare system and explore admissions to general wards versus Mother and Baby Units and transitions between these units. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14. Mother and Baby Units are special psychiatric facilities designed to provide inpatient care for women dealing with serious mental health problems during pregnancy or after giving birth. In recent years, there have been attempts to improve these services. However, we still do not have much information about how patients get to these units. In this study, we wanted to learn how women reach Mother and Baby Units in the United Kingdom. We studied three different locations: Birmingham, London and Nottingham. We reviewed the electronic records of 198 women who used Mother and Baby Units in these locations during 2019. Here is what we found: Most patients were admitted to the Mother and Baby Unit after giving birth, and they were usually admitted in an emergency. On average, they stayed in the Unit for about 6 weeks. We found differences between services in how patients were admitted, how long they stayed, the reasons they were admitted and how long it took them to reach the Unit. When we looked at what affects a patient’s journey to the Mother and Baby Unit, we found that ethnicity played an important role. For example, more Asian women were admitted in emergencies, and black women went through fewer services before reaching the Unit. The study sheds light on how patients access Mother and Baby Units, showing that the process varies by location. It also found that ethnicity plays a role. For example, black patients had fewer steps to reach the Unit compared to White British patients. This could mean direct access to care or a lack of community-based support. More research is needed to determine whether this is due to clinical decisions or gaps in the care system. eng
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Recovery-oriented psychiatry : oxymoron or catalyst for change?This Personal View provides a normative and conceptual analysis of the intersection between the recovery movement and psychiatry. Although recovery emerged as a grassroots social justice movement emphasising empowerment and systemic change, psychiatry remains rooted in the medical paradigm. We aim to develop a nuanced conceptual framework that fosters academic debate and meaningful implementation, while avoiding superficial or tokenistic adoption of recovery principles. Our analysis explores the contrasting values, ontologies, and epistemologies of these perspectives, identifying points of tension and areas of compatibility. We examine and discuss integrative and non-integrative pluralistic approaches, and we conclude with actionable recommendations for transformation at different organisational levels.
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A quantitative investigation of inequalities in out-of-area admissions in child and adolescent mental health servicesBackgroundUnderstanding inequalities in mental health care is vital for the development of more equitable services. This study investigates inequalities in out-of-area admissions to general adolescent units, a controversial but necessary part of Child and Adolescent Mental Health care in England.MethodsAnonymised data on 279 out-of-area (at-distance or out-of-region) admissions to general adolescent units in England between February 2021-2022 were analysed for an association between demographics (age, sex, ethnicity) or clinical characteristics (diagnosis and risks) and admission characteristics (7+ day wait for a bed, distance from home, admission out-of-region, compulsory admission and length of stay >6 months).ResultsNo association was found between demographic characteristics and admission characteristics. Personality disorder was the only diagnosis associated with admission greater distance from home. Young people with personality disorder or neurodevelopmental disorder were more likely to be admitted compulsorily (OR = 8.89 and OR = 1.93 respectively). Those with suicide risk were more likely to be admitted non-compulsorily (OR = 2.06) but more likely to be admitted out-of-region (OR = 2.25).DiscussionWithin these data, the clinical presentation of the young person influenced their out-of-area admission characteristics. Young people with a diagnosis of personality disorder may be particularly likely to experience more negative aspects of out-of-area admission. Due to the number and uneven spread of specialist mental health beds throughout the country, young people may be admitted far-away from where they live (more than 50 miles from their home address or out of their local region). Previous research has shown inequalities in the care received by young people based on their demographics and diagnoses. This study looks at whether there is evidence of this unequal treatment based on demographics, diagnoses, and risks within a sample of young people admitted far-away from home. Statistical tests were used to look for whether there was evidence that the demographics (age, sex and ethnicity) or presentation (diagnoses or risks) of a young person were associated with negative aspects of an admission (having to wait for a week or more for a bed, longer distance from home, being admitted out-of-region, spending more than 6 months in hospital and having to be admitted against their will). The researchers found no links between demographics and negative aspects of the admission in this data. However, they found that young people with a diagnosis of a personality disorder were sent on average further away than those who did not have this diagnosis, they were also more likely to be admitted against their will. Young people with a neurodevelopmental disorder (autism spectrum disorder, attention-deficit hyperactive disorder or Tourette’s syndrome) were also more likely to be admitted against their will. Young people judged to be at high risk of suicide were more likely to be sent out-of-region and less likely to be admitted against their will. These findings do not show evidence of unequal treatment based upon demographics but potential inequalities due to diagnosis and risks. The reason for these differences may represent stigma against young people with certain diagnoses such as personality disorder. eng
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Programmes for people who are homeless and have severe mental illness in low-income and middle-income countries : a systematic reviewHomelessness and severe mental illness are inter-related issues, the co-occurrence of which leads to poor outcomes for affected individuals. Evidence for effective interventions in high-income countries is accruing, but little is known about how to intervene in the diverse sociocultural contexts of low-income and middle-income countries (LMICs). The aim of this systematic review was to synthesise peer-reviewed and grey literature on programmes for people experiencing homelessness and severe mental illness in LMICs. We synthesised effects, programme components, and implementation strategies. We identified 80 sources describing 45 programmes across ten LMICs. Programme components spanned seven domains: service models, basic needs, health care, outreach, empowerment, community level, and macro level. Most programmes were multicomponent and included diverse delivery agents. Evaluation studies (n=21), although few in number and quality, reported clinical improvements; family reintegration ranged from 6% to 69%. Frequently reported implementation strategies included network weaving, educational meetings, and involvement of patients and family members. We identified programmes that show promise and can serve as starting points for local adaptation. This systematic review identifies common domains of programmatic interventions that are important to include in combination for future programme design, while considering local contexts and population-specific needs. Future research should prioritise rigorous evaluations, with particular emphasis on programme effects and cost benefits.
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Principles of Industry-Academic Partnerships Informed by Digital Mental Health Collaboration : Mixed Methods StudyBACKGROUND: Cross-sector collaboration is increasingly recognized as essential for addressing complex health challenges, including those in mental health. Industry-academic partnerships play a vital role in advancing research and developing health solutions, yet differing priorities and perspectives can make collaboration complex. OBJECTIVE: This study aimed to identify key principles to support effective industry-academic partnerships, from the perspective of industry partners, and develop this into actionable guidance, which can be applied across sectors. Mental health served as a motivating example due to its urgent public health relevance and the growing role of digital innovation. METHODS: Using a 3-stage, mixed-methods approach, we conducted a web-based survey of UK-based digital mental health companies (N=22) to identify key barriers and facilitators to industry-academic partnerships. This was followed by 2 focus groups (n=5) that explored emerging themes from the survey using thematic analysis. Finally, we conducted a workshop with industry representatives, researchers, clinicians, and PPI members to co-develop the Principles of Industry-Academic Partnerships (PIP) guidance. RESULTS: Survey findings highlighted that industry partners valued academic collaboration for enhancing credibility, facilitating knowledge transfer, and gaining access to PPI networks. However, key barriers included high costs, slow academic timelines, and complex contracting processes. The 4 major themes that emerged from the focus groups were: advantages of collaboration, cultural differences between organizations, collaboration models, and structural barriers within universities. Through informed discussions in the workshop, these themes were explored, leading to the development of 14 actionable strategies. These strategies reflect industry perspectives and formed the PIP guidance, categorized under project initiation, defining the scope and agreements, project execution, and promoting sustainability. CONCLUSIONS: The PIP guidance provides a practical framework to support more effective and mutually beneficial collaborations between industry and academia. Developed through the lens of mental health research, the strategies identified are broadly applicable across disciplines where cross-sector partnerships are essential. Industry partners valued academic collaborations for their credibility and scientific rigor, but highlighted persistent structural and cultural barriers within universities. Addressing these challenges by aligning expectations and timelines, adopting flexible collaboration models, and streamlining operational processes can help foster impactful and sustainable partnerships in mental health and beyond.
