Accessible Summary What is known about the subject? The practices of mental health nurses in the administration of repetitive transcranial magnetic stimulation (rTMS) treatments for depression in outpatient clinic are crucial for patient outcomes To date, most research has focused directly on procedural aspects of treatment delivery with limited focus on the delivery of holistic care and treatment. There is a lack of best practice guidance based on the experiences of those involved in clinical delivery to inform and improve rTMS practices. What this paper adds to existing knowledge? This study provides unique insights into service and personalized non-treatment factors associated with rTMS delivery that may reduce stress and improve the experiences of rTMS patients. It reviews and updates understanding of the factors that contribute to the delivery of effective rTMS. What are the implications for practice? The need to apply findings for the development of best practice guidance. Factors to improve practice include (a) rTMS machine demonstrations; (b) constructive, individualized, friendly, and therapeutic conversations; (c) a relaxing, comfortable, 'homely' physical environment; (d) long term supportive management; and (e) careful engagement of nursing and support staff.

Purpose Depression, physical health, well-being, sleep and physical activity are interlinked. Healthy levels of physical activity and effective night-time sleep can reduce depressive symptoms. In the context of their lives and symptoms of depression, this paper aims to understand participants’ experiences of using a Fitbit, physical activity and sleep and the barriers and facilitators for healthy sleep and physical activity. Design/methodology/approach Qualitative methods were used to conduct interviews with 19 patients (4 male; 15 female) diagnosed with treatment-resistant depression undergoing transcranial magnetic stimulation (TMS) treatment for depression. Reflexive thematic analysis was used. Findings Healthy sleep and physical activity levels are interlinked and reduce depressive symptoms as well as improving well-being and physical health. A Fitbit is useful to enhance physical activity, self-awareness, motivation, healthier lifestyles and effective sleep. Barriers to healthy sleep and physical activity levels included depressive symptoms, environmental factors and anxieties. Facilitators for healthy sleep and physical activity levels included knowledge of the benefits, support from family and friends and applying sleep hygiene. Practical implications There is a need to provide interventions using wearable activity trackers that build on the links between increased physical activity, improved sleep, enhanced well-being, better physical health and lower depressive symptoms. Originality/value To the best of the authors’ knowledge, this is the first time that patients undergoing TMS have had their experiences of sleep, activity and using a Fitbit investigated and reported.

Background Repetitive transcranial magnetic stimulation (rTMS) is effective in treating depression; however, the effect on physical activity, sleep and recovery is unclear. This study investigated rTMS effect on physical activity and sleep through providing patients with a Fitbit and software apps; and reports the impact of rTMS on depression, anxiety and mental health recovery. Methods Study design was a pre and post data collection without a control, with twenty-four participants with treatment-resistant depression (TRD). Measures used were Fitbit activity and sleep data, and patient-rated Recovering Quality of Life (ReQoL-20), Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder (GAD-7). Results Response and remission rates were, respectively: 34.8% and 39% for PHQ-9; 34.8% and 47.8% for GAD-7. ReQoL-20 response and reliable improvement were 29.4% and 53%. PHQ-9, GAD-7 and ReQol-20 scores significantly improved, with large effect sizes. Analysis of Fitbit activity and sleep data yielded non-significant results. The Fitbit data machine learning model classified two levels of depression to 82% accuracy. Limitations rTMS treatment was open-label and adjunct to existing antidepressant medication. No control group. Female patients were overrepresented. Conclusions Improvements on the ReQoL-20 and aspects of sleep and activity indicate the positive impact of rTMS on the individual's real world functioning and quality of life. A wearable activity tracker can provide feedback to patients and clinicians on sleep, physical activity and depression levels. Further research could be undertaken through a sufficiently powered RCT comparing rTMS versus rTMS with use of a Fitbit, its software applications, and sleep and physical activity advice.

Background: Evidence has shown that self-guided web application mindfulness training can improve mental health. In this study, the “Be Mindful” online-based mindfulness training software application was offered through a United Kingdom (UK) universal community healthcare provider to patients with a mental illness diagnosis. Be Mindful is an online course providing instruction on mindfulness theories and practice training, progress tracking, integrated guidance/feedback, and motivational emails. Objective: The aim of this paper is to present feasibility findings and outcomes on anxiety, depression, and stress of an intervention offering Be Mindful. Participants were adults who had a mental illness diagnosis and were under the care of community mental health services. Methods: Open-label patient cohort design, with no control group. Pre- and post-intervention assessment using participant self-report measures: Generalised Anxiety Disorder-7 (GAD-7); Perceived Stress Scale (PSS-10); and Patient Health Questionnaire-9 (PHQ-9; a measure of depression severity). Results: Two hundred and seventy-four started and thirty-one patients completed the Be Mindful programme and outcome measures. PSS scores at baseline significantly improved from 24.6 (1.79) to 18.7 (2.05) at the end (p < 0.001), with a large effect size of 0.498. GAD-7 scores at baseline significantly improved from 11.4 (1.3) to 8.00 (1.35) at end (p < 0.001), with a medium effect size of 0.354. PHQ-9 scores at baseline significantly improved from 13.7 (1.42) to 9.09 (1.76) to 9.81 (1.77) at end (p < 0.001), with a medium effect size of 0.378. Limitations: There was no control group, and the intervention was adjunct to existing treatment. Conclusions: Be Mindful can be offered through a UK community NHS Trust and can have a significant impact on symptoms of anxiety, depression, and stress in patients with experience of mental illness. Roll-out through community mental health providers to people with experience of mental illness is justified. Well-designed and sufficiently powered randomised controlled trials of theory-driven online mindfulness training for mental illness patient populations are required.

Abstract Background: There is limited evidence of the longer-term impact of the COVID-19 pandemic on acute admissions for psychosis in the UK. Aims: We examined the impact of COVID-19 on rates of admissions for first and repeated episode psychosis, and changes in patient profile and seasonal patterns, over a period of 12 months. Method: We conducted a retrospective case note review of all patients admitted with a primary psychosis (F20-29 ICD 10 diagnosis) to an NHS psychiatric inpatient unit. We compared the 12 months pre-COVID-19 period between 1 March 2019 and 28 February 2020, and the 12 months post-COVID-19 period between 1 March 2020 and 28 February 2021. Results: The results showed increase rates of admissions post-COVID-19 in both first and repeated episode psychosis, the patient profile had more females and older age in the repeated episode group, with increased employment rates. Combined group data for both pre- and post-COVID-19 periods showed an increased trend in spring and summer admissions, and even though not statistically significant, more pronounced post-COVID-19. Conclusions: Our findings highlight the effect of the COVID-19 pandemic on acute psychosis admissions over a 12-month period. The results provide evidence for the ‘stress-pathogenesis’ in the context of genetic vulnerability in psychosis. Preventative strategies in the context of the ‘stress-pathogenesis model’, improved access to and responsiveness within NHS transformation efforts needs to be adjusted to fit local need and environmental changes.

Abstract Background: Symptoms of anxiety disorders are highly common and can have a severe impact on people’s lives; they are typically treated with psychotherapy and/or anti-anxiety medication. These treatments are not suitable for, acceptable to, or effective for everyone. Alpha-Stim AID is a cranial electrotherapy stimulation (CES) device with evidence of effectiveness in treating symptoms of anxiety. In this study, Alpha-Stim AID was offered through a United Kingdom (UK) universal community healthcare provider, Intermediate Care Team (ICT) community healthcare service to patients who reported signs of anxiety. Objective: The aim of this paper is to present feasibility findings and outcomes on anxiety, health status, and quality of life. Methods: Open-label patient cohort design, with no control group. Participants were adults who reported symptoms of anxiety and were under the care of universal national health service (NHS) Intermediate Care Team (ICT) community healthcare service in the United Kingdom (UK). Pre- and post-intervention assessment used participant self-report measures: generalised anxiety disorder (GAD-7) and health related quality of life (EQ-5D-5L). The three ICT staff members who offered the Alpha-Stim AID to patients completed a questionnaire on their experience. Results: Eighteen patients used the Alpha-Stim and completed outcome measures. GAD-7 scores significantly improved from 13.9 (SD = 4.3) to 7.3 (SD = 5.7) (p < 0.001), with a large effect size of 0.88. Analysis of EQ-ED-5L health index score conversions indicated perceived quality of life increased from 0.31 (SD = 0.25) to 0.48 (SD = 0.28) at end (p = 0.036), with a small effect size of 0.12. EQ-VAS scores at baseline improved from 49.2 (SD = 24.0) to 64.4 (SD = 26.2) at the end (p = 0.05), with a small effect size of 0.12. Limitations: There was no control group, and the intervention was adjunct to existing treatments. Conclusions: Alpha-Stim AID CES can be offered through a UK NHS Trust Intermediate Care Team (ICT) community healthcare service and can have a significant positive impact on symptoms of anxiety, quality of life, and health status in patients who report experience of anxiety symptoms. Roll-out through community mental health providers to people with experience of anxiety symptoms is feasible. An appropriately designed and sufficiently powered randomised controlled trial of Alpha-stim for anxiety is required.

Background Randomised sham-controlled trials of cranial electrostimulation with the Alpha-Stim Anxiety Insomnia and Depression (AID) device have reported improved anxiety and depression symptoms; however, no adequately powered sham-controlled trials in major depression are available. We investigated whether active Alpha-Stim AID is superior to sham Alpha-Stim AID in terms of clinical effectiveness for depression symptoms in major depression. Methods The Alpha-Stim-D trial was a multicentre, parallel group, double-blind, randomised controlled trial, recruiting participants from 25 primary care centres in two regions in England, UK. Eligible participants were aged 16 years or older with a current diagnosis of primary major depression, a score of 10–19 on the nine-item Patient Health Questionnaire, and had been offered or prescribed and reported taking antidepressant medication for at least 6 weeks in the previous 3 months. Main exclusion criteria were contraindications to Alpha-Stim AID device use, having persistent suicidal ideation or self-harm, neurological conditions, a substance use disorder or dependence, an eating disorder, bipolar disorder, or non-affective psychosis, or receiving psychological treatment in the past 3 months. Eligible participants were randomly assigned (1:1, minimised by region, anxiety disorder, and antidepressant use) to 1 h daily use of active (100 μA) or sham Alpha-Stim AID treatment for 8 weeks. Randomisation was via an independent web-based system, with participants, outcome assessors, and data analyst masked to treatment assignment. The primary outcome was change from baseline in score on the 17-item Hamilton Depression Rating Scale (HDRS-17, GRID version) at 16 weeks after randomisation, with participants analysed by intention to treat (ITT; all randomly assigned participants). Safety was assessed in all randomly assigned participants. The trial is registered with the ISRCTN registry (ISRCTN11853110); status completed. Findings Between Sept 8, 2020, and Jan 14, 2022, 236 eligible participants were randomly assigned to active or sham Alpha-Stim AID (n=118 each). 156 (66%) participants were women, 77 (33%) were men, and three (1%) self-reported as other gender; 200 (85%) were White British or Irish; and the mean age was 38·0 years (SD 15·3; range 16–83). 102 (86%) participants in the active Alpha-Stim AID group and 98 (83%) in the sham group were followed up 16 weeks after randomisation. In the ITT population, mean change in GRID-HDRS-17 at 16 weeks was –5·9 (95% CI –7·1 to –4·8) in the active Alpha-Stim AID group and –6·5 (–7·7 to –5·4) in the sham group (mean change difference –0·6 [95% CI –1·0 to 2·2], p=0·46). Among the 236 participants, 17 adverse events were reported in 17 (7%) participants (nine [8%] participants in the active Alpha-Stim AID group; and eight [7%] participants in the sham group). One serious adverse event of suicidal ideation leading to hospitalisation was reported in the sham group, which was judged to be unrelated to the device. Interpretation Active Alpha-Stim AID was safe and acceptable, but no more clinically effective than sham Alpha-Stim AID in major depression. Funding

Purpose There is a lack of research informing service requirements for older (aged≥55 years) forensic mental health patients. The aim of this research was to increase knowledge about older forensic mental health patients’ quality of life, wellbeing, recovery, and progress, in order to make recommendations of how to facilitate and enhance these factors. Methods In-depth interviews with patients (N = 37) and staff (N = 48) were undertaken; data were analysed using thematic analysis. Results Environmental (e.g., physical, structural and facilities), relational (staff, family and friends) and individual (characteristics, feelings, behaviours) factors were identified as enablers and/or obstacles to wellbeing, recovery, progress and quality of life. Conclusions The physical and psychological environment of services needs to be adapted to meet the needs of patients. Therapeutic relationships with staff should be encouraged and a person-centred and individual recovery approach adopted. Prosocial relationships with peers, friends and family need to be fostered to enable positive recovery outcomes. Older patients should be empowered to develop a sense of autonomy to enable quality of life, wellbeing, and recovery, and progress.

Abstract Background It is important to investigate the needs, experiences, and outcomes of older forensic mental health inpatients. In this consensus document, we offer practitioners working with older forensic inpatients recommendations to meet the unique older-age-related needs of this group. Method We report on the findings of a scoping review of service provision and age-responsive interventions for this population. We complement this with a review of qualitative studies investigating staff and patient views on age-responsive inpatient care. Results The guidance synthesizes this evidence into sections on: epidemiological studies of demographic, clinical, and legal profiles; qualitative studies; investigations of patient need; evidence for interventions tailored to this patient group; future directions for research; and finally, recommendations for practice. Forensic patients over the age of 50 years have a different set of psychological and physical health needs from their peers. There is a dearth of dedicated interventions and support to assist patients through secure services and into the community. Conclusions We suggest service providers involve older patients in treatment and service organization decisions, adapt interventions to be responsive to this group, train staff to recognize physical vulnerabilities and cognitive decline, and embrace methods of communication developed in other areas of care, such as dementia Care.