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Objectives: People with mental illness may be vulnerable to psychological distress and reduced well-being during the COVID-19 pandemic. The aim of this study was to assess psychosocial and lifestyle predictors of distress and well-being in people with mental illness during the pandemic. Method: People with mental illness who participated in an exercise programme prior to the pandemic were invited to complete surveys about mental health and lifestyle corresponding to before and during the pandemic. Results: Social support reduced, alcohol intake increased, and sleep quality and diet worsened during the pandemic, contributing to distress. Psychological distress was associated with the two or more mental illnesses, and negatively associated with having a physical disease. Better diet appeared to protect against increases in distress; loneliness hindered improvements in well-being. Conclusions: Healthy lifestyle programmes designed to improve social connection may improve health for people with mental illnesses during and after the COVID-19 pandemic.

Background The intensive care environment and experiences during admission can negatively impact patient and family outcomes and can complicate recovery both in hospital and after discharge. While their perspectives based on intimate experiences of the environment could help inform design improvements, patients and their families are typically not involved in design processes. Rather than designing the environment around the needs of the patients, emphasis has traditionally been placed on clinical and economic efficiencies. Objective The main objective was to inform design of an optimised intensive care bedspace by developing an understanding of how patients and their families experience the intensive care environment and its impact on recovery. Methods A qualitative descriptive study was conducted with data collected in interviews with 17 intensive care patients and seven family members at a large cardiothoracic specialist hospital, analysed using a framework approach. Results Participants described the intensive care as a noisy, bright, confronting and scary environment that prevented sleep and was suboptimal for recovery. Bedspaces were described as small and cluttered, with limited access to natural light or cognitive stimulation. The limited ability to personalise the environment and maintain connections with family and the outside world was considered especially problematic. Conclusions Intensive care patients described features of the current environment they considered problematic and potentially hindering their recovery. The perspective of patients and their families can be utilised by researchers and developers to improve the design and function of the intensive care environment. This can potentially improve patient outcomes and help deliver more personalised and effective care to this vulnerable patient population and their families.

Interventions that promote exercise and a healthy diet can improve quality of life and may promote recovery for people with mental health issues. The aim of this study was to evaluate a community-b...

Exercise has diverse benefits for physical and mental health in people with mental illness; however, it is unclear how to effectively promote exercise motivation in this group. The aim of this study is to evaluate the effectiveness of interventions utilising exercise instruction or behavioural counselling with people with mental illness to improve self-determined motivation for exercise, and physical and mental health. Participants were adults (aged 18+ years) receiving mental health services. Participants could choose from two 8-week programs comprising weekly group-based sessions delivered by an exercise physiologist: (a) exercise instruction in a gym (GYM) or (b) behavioural counselling (MOT). Self-determined motivation was measured using the Behaviour Regulations for Exercise Questionnaire (BREQ3). Physical health indicators included waist circumference, blood pressure, leg strength (sit-to-stand test), physical capacity (six-minute walk test) and self-reported exercise. Mental health was assessed using the Kessler-6 scale of psychological distress. Most of the 95 participants chose exercise instruction (GYM = 60; MOT = 35). At baseline, participants who chose MOT had higher external motivation, body mass index, waist circumference and psychological distress, and a higher proportion had multiple physical comorbidities than those who chose GYM. More self-determined motivation was associated with meeting physical activity guidelines. Post-intervention, GYM participants had significant improvements in self-determined motivation, psychological distress and sit-to-stand test; MOT participants had significant improvements in integrated regulation, self-reported exercise and physical functioning. In conclusion, exercise instruction can improve self-determined motivation; however, more intensive behavioural counselling support may be needed to improve self-determined motivation. Counselling programs can increase exercise behaviour and may appeal more to people with poorer health and more external motivation. Findings have high ecological validity and applicability to real-world implementation of exercise interventions. To accommodate people with diverse conditions and motivations, motivational counselling should be combined with practical exercise support, and participants afforded the autonomy to decide their level of involvement.

Clinical research and technological innovation have greatly improved survival after admission to intensive care units (ICU), such that around 90% of patients are discharged.1 However, their recovery is often complicated and partial.2 Longitudinal studies have demonstrated that physical, cognitive, and psychiatric morbidity are prevalent post‐discharge, with impairment often persisting for years.3-6 Concerned with promoting quality of survival, the Society of Critical Care Medicine (SCCM) convened a 2‐day conference in 2012 to develop strategies for improving long‐term outcomes of critical illness for patients and family members.2 The term “post‐intensive care syndrome” (PICS) was coined to represent impairment and disability arising after a critical illness and persisting beyond acute hospitalization.

Background: Critically ill patients are more likely to survive intensive care than ever before due to advances in treatment. However, a proportion subsequently experiences post-intensive care syndrome (PICS) incurring substantial personal, social, and economic costs. PICS is a debilitating set of physical, psychological, and cognitive sequelae but the size and characteristics of the affected population have been difficult to describe, impeding progress in intensive care rehabilitation. Aims and objectives: The aim of this protocol is to describe recovery after admission to intensive care unit (ICU) and the predictors, correlates, and patient-reported outcomes for those experiencing PICS. The study will support the development of screening, diagnostic, and outcome measures to improve post-ICU recovery. Design: A prospective, multi-site observational study in three ICUs in Brisbane, Australia. Following consent, data will be collected from clinical records and using validated self-report instruments from 300 patients, followed up at 6 weeks and 6 months post ICU discharge. Methods: TOPIC is a prospective, multi-site observational study using self-report and clinical data on risk factors, including comorbidities, and outcomes. Data will be collected with consent from hospital records and participants 6 weeks and 6months post ICU discharge. Results: The main outcome measures will be self-reported physical, cognitive, and psychological function 6 weeks and 6 months post-ICU discharge. Relevance to Clinical Practice: This protocol provides a methodological framework to measure recovery and understand PICS. Data analysis will describe characteristics associated with recovery and PICS. The subsequent prediction and screening tools developed then aim to improve the effectiveness of post-ICU prevention and rehabilitation through more targeted screening and prediction and found a program of research developing a more tailored approach to PICS.

The oral health of people with severe mental illness is severely compromised. Rates of premature total tooth loss and tooth decay are substantially higher than in the general population. Causation is complex, restricted access to treatment a major contributing factor.To examine factors enabling people with complex problems related to severe mental illness to attend scheduled dental appointments.Qualitative semi-structured interviews were conducted with 15 service users who attended no-cost treatment at a university clinic, following oral health screening at an inner-city community mental health service. Analysis used a framework approach informed by a theoretical model of behaviour (COM-B).Complex individual motivations, related variously to function, pain and/or self or social appraisal, were also influenced by expectations of treatment. Capabilities included managing "messy" life circumstances; participants overcame various psychological and physical challenges to attend treatment, enabled by opportunities of social and instrumental support.Genuine partnerships between agencies to provide access opportunities, in addition to individual support responsive to personal motivators and adapted to capabilities can enable access to services and improve the lives of people with severe mental illness.

Delirium, a common complication of an intensive care unit (ICU) admission, is inconsistently diagnosed by clinicians. Current screening tools require specialist expertise and/or training. Some are time-consuming to administer, and reliability in routine clinical practice is questionable. An innovative app designed to enable efficient and sensitive screening for delirium without specialist training (eDIS-ICU) has recently been described. This pilot study compared the eDIS-ICU against the reference standard expert assessment using DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria and the Confusion Assessment Method for the ICU (CAM-ICU).In this prospective, single-centre pilot study, a convenience sample of 29 ICU patients were recruited at a tertiary referral hospital between November 2018 and August 2019. After obtaining written consent, demographic and clinical data were collected, and the patients were screened for delirium using eDIS-ICU and CAM-ICU by two clinician researchers in random order. The patients were also assessed for presence of delirium independently by an expert clinician using a structured interview to diagnose as per DSM-V criteria. The results of screening and diagnosis were tabulated to allow comparison of screening tools against diagnosis; sensitivity and specificity of the tools were calculated.Seven participants were diagnosed with delirium as per DSM-V criteria. The eDIS-ICU tool correctly identified six of these participants compared with two identified by CAM-ICU. The sensitivity of the eDIS-ICU tool was 86% (95% confidence interval [CI] = 81.5-100.0) compared with 29% (95% CI = 5.1-69.7) for CAM-ICU (p 0.05), and the specificity was 73% (95% CI = 81.5-100.0) versus 96% (95% CI = 75.1-99.8), respectively.The simple and novel eDIS-ICU delirium screening tool was noninferior to the CAM-ICU in detecting delirium as per DSM-V criteria. A definitive validation study is warranted.

Objectives: To describe prescription of sodium valproate (SV) for bipolar mood disorder to potentially child-bearing women within one public mental health service and describe risks of fetal exposure, and safe prescribing practices among psychiatrists. Methods: A 24-month retrospective chart review with descriptive analysis; narrative review of literature and guidelines. Results: Review of 383 charts demonstrated prescription of valproate to 20% of 98 women aged 15–45, with little evidence of advice regarding risk and contraception. Robust evidence of teratogenic and neurodevelopmental risk underpins increased regulation, and recommendations that valproate not be prescribed to this cohort. Conclusions: The significant risks associated with SV oblige all prescribers to proactively access authoritative guidelines such as those published by the Centre of Perinatal Excellence.

BackgroundAntineuronal antibodies are associated with psychosis, although their clinical significance in first episode of psychosis (FEP) is undetermined.AimsTo examine all patients admitted for treatment of FEP for antineuronal antibodies and describe clinical presentations and treatment outcomes in those who were antibody positive.MethodIndividuals admitted for FEP to six mental health units in Queensland, Australia, were prospectively tested for serum antineuronal antibodies. Antibody-positive patients were referred for neurological and immunological assessment and therapy.ResultsOf 113 consenting participants, six had antineuronal antibodies (anti-N-methyl-D-aspartate receptor antibodies [n = 4], voltage-gated potassium channel antibodies [n = 1] and antibodies against uncharacterised antigen [n = 1]). Five received immunotherapy, which prompted resolution of psychosis in four.ConclusionsA small subgroup of patients admitted to hospital with FEP have antineuronal antibodies detectable in serum and are responsive to immunotherapy. Early diagnosis and treatment is critical to optimise recovery.Declaration of interestNone.

While therapeutic relationships are appropriately recognised as the foundation of mental health service, service users commonly report suboptimal experiences. With shared understanding critical to improvement in practice, we explored service users' experiences and expectations of psychiatrists and consultations, engaging psychiatrists throughout the process. Using an iterative qualitative approach we co-produced a response to the question 'what makes an excellent mental health doctor?' Experiences and expectations of psychiatrists were explored in interviews with 22 service users. Data collection, analysis and interpretation were informed by consultation with peer workers. Findings were contextualised in formal consultations with psychiatrists. As 'masters of their craft', excellent mental health doctors engage authentically with service users as people (not diagnoses). They listen, validate experiences and empathise affectively and cognitively. They demonstrate phronesis, applying clinical knowledge compassionately. Psychiatrists share service users' aspiration of equitable partnership but competing demands and 'professional boundaries' constrain engagement. Consistent delivery of the person-centred, recovery-oriented care promoted by policy and sought by service users will require substantial revision of the structure and priorities of mental health services. The insights and experiences of service users must be integral to medical education, and systems must provide robust support to psychiatrists.

Background While the impact of the intensive care environment on patients’ experiences and outcomes has been extensively studied, relatively little research has examined the impact on clinicians and their provision of care in the intensive care unit (ICU). Understanding staff experience and views about the environment is needed to optimise the ICU environment, patient outcomes and staff wellbeing. Objective The objective of this study was to inform design of an optimised intensive care bedspace by describing clinicians’ views about the current environment, including experience, impact on performance of clinical duties, and experience and outcomes of patients and family members. Methods A pragmatic, qualitative descriptive study was conducted, with data collected in focus groups and interviews with 30 intensive care clinicians at a large cardiothoracic specialist hospital and analysed using the framework approach. Results Participants acknowledged that the busy and noisy ICU provided a suboptimal healing environment for patients, was confronting for visiting families and exposed clinicians to risk of psychological injury. The bedspace, described as small and cluttered, hindered provision of clinical care of various kinds and contributed to an increased risk of staff physical injuries. Participants noted that the bland, sterile environment, devoid of natural light and views of the outside world, negatively affected both staff and patients’ mood and motivation. Aware of the potential benefits of natural light, cognitive stimulation and visually appealing environments for patients and families, clinicians were frustrated by their inability to personalise the bedspace. Some participants, while acknowledging the importance of family contact for patients, were concerned about the impact of visitors on care delivery, particularly within already crowded bedspaces, suggesting restrictions on visiting. Conclusions Intensive care clinicians perceive that the current intensive care environment is suboptimal for patients, their families and staff and may contribute to suboptimal patient outcomes. The intensive care bedspaces need to be redesigned to ensure they are built around the needs of the people using them. Optimisation is dependent on engaging all stakeholders in future design processes.

Background Perinatal depression and/or anxiety disorders are undertreated pregnancy complications. This is partly due to low rates of engagement by women. This study aimed to identify barriers and facilitators to women accessing perinatal mental health services in an outer metropolitan hospital in Queensland, Australia. Methods Data was collected from pregnant women through a cross-sectional survey. Women rated the extent certain factors influenced their engagement. Respondents were separated into three groups: women who were not offered a referral to perinatal mental health services, women who were offered a referral but did not engage, and women who engaged. Results A total of 218 women participated. A response rate of 71% was achieved. 38.1% of participants did not believe themselves knowledgeable about mental illness in the perinatal period, and 14.7% did not recall being asked about their mental health during their pregnancy. Of those participants who recalled being asked about their mental health, 37.1% were offered a referral. Of these, just over a third (36.2%) accepted, and out of this group, 40% attended an appointment. Regardless of referral and engagement status, the factors identified as influencing participant engagement were time restraints, lack of childcare support, and encouragement by family and health care professionals. Stigma was not identified as a barrier. Conclusions Perinatal mental health service engagement could be improved by health services: ensuring universal screening and actively engaging women in the process: assisting with childcare; improving appointment immediacy and accessibility; and educating health care professionals about their influence on women’s engagement. Electronic supplementary material The online version of this article (10.1186/s12884-019-2320-9) contains supplementary material, which is available to authorized users.

Aims and methodTo describe and explain psychiatrists' responses to metabolic abnormalities identified during screening. We carried out an audit of clinical records to assess rates of monitoring and follow-up practice. Semi-structured interviews with 36 psychiatrists followed by descriptive and thematic analyses were conducted.ResultsMetabolic abnormalities were identified in 76% of eligible patients screened. Follow-up, recorded for 59%, was variable but more likely with four or more abnormalities. Psychiatrists endorse guidelines but ambivalence about responsibility, professional norms, resource constraints and skills deficits as well as patient factors influences practice. Therapeutic optimism and desire to be a ‘good doctor’ supported comprehensive follow-up.Clinical implicationsPsychiatrists are willing to attend to physical healthcare, and obstacles to recommended practice are surmountable. Psychiatrists seek consensus among stakeholders about responsibilities and a systemic approach addressing the social determinants of health inequities. Understanding patients' expectations is critical to promoting best practice.

IntroductionPhysical activity (PA) has diverse benefits for physical and mental health and can reduce symptoms of mental illness. Adults with mental illness face practical, psychosocial and socioeconomic barriers to adopting and maintaining PA, and it is unclear how to effectively promote PA in this group. Supervised exercise interventions provide high support but may not promote autonomous motivation, which is important for PA maintenance. The aim of this study is to compare the effectiveness of two interventions to promote PA in adults with mental illness.Methods and analysisThis is a randomised controlled trial of two interventions to promote PA: (1) supervised exercise and gym membership and (2) motivational discussions and self-monitoring of PA using fitness trackers. The intervention duration is 16 weeks, including 8 weeks of weekly supervised group sessions, and 8 weeks of access to the gym or fitness tracker unsupervised. Participants are community-dwelling adults recruited from outpatient clinics of public mental health services. The primary outcome is PA adoption assessed using GENEActiv accelerometers worn continuously over 8 weeks. Secondary outcomes measured at baseline, postintervention (8 weeks) and follow-up (16 weeks), include exercise motivation, psychological distress and self-reported PA assessed using self-administered questionnaires and indicators of physical health measured by a researcher blinded to allocation (blood pressure, weight, waist circumference, 6 min walk test). Participant experiences will be assessed using qualitative focus groups with analysis informed by a theoretical model of behaviour (COM-B).Ethics and disseminationEthics approval has been obtained from the Royal Brisbane and Women’s Hospital (HREC/17/QRBW/302). We plan to submit a manuscript on protocol development from pilot work, and a manuscript of the results to a peer-reviewed journal. Results will be presented at conferences, community and consumer forums and hospital grand rounds.Trial registration numberACTRN12617001017314; Pre-results.

IntroductionClozapine, while effective in treatment refractory schizophrenia, is associated with significant weight gain, heart disease and increased risk of type 2 diabetes mellitus (T2DM). Although there is evidence for weight loss with metformin for people with obesity who are already taking clozapine, there have been no published trials that have investigated the effect of metformin in attenuating weight gain at the time of clozapine initiation.Methods and analysisA 24-week double-blind placebo-controlled trial of concomitant prescription of metformin at clozapine commencement. Eighty-six people being commenced on clozapine will be randomised to placebo or metformin (variable dose, up to 2 g/day). The primary outcome is comparative end point body weight, between the placebo and metformin groups. Secondary outcomes are comparative rates of conversion to T2DM, alteration of metabolic syndrome parameters, proportion gaining >5% body weight and changes in diet and appetite. We will additionally examine biomarkers associated with change in weight among trial participants.Ethics and disseminationEthics approval was granted by the Metro South Human Research Ethics Committee HREC/17/QPAH/538-SSA/17/QPAH/565. We plan to submit a manuscript of the results to a peer-reviewed journal, and present results at conferences, consumer forums and hospital grand rounds.Trial registration numberACTRN12617001547336; Pre-results.

Art therapists have been unsettled by the findings of a pragmatic randomised controlled trial testing the addition of group-based art therapy to standard care for people diagnosed with schizophrenia. Arguments that the therapy tested was not that routinely delivered in the UK have been fuelled by the arguably scant descriptions of therapy published to date. To inform the important debate about implications of findings, we provide a comprehensive description of therapy delivered in MATISSE. Drawing on accounts of therapists, their supervisors and participants and study documents, we articulate the three models used to deliver therapy. Described as modified studio, phased group and potentially interactive art therapy, the models were differentiated by structure and the degree of interpersonal and types of therapeutic interaction encouraged. Therapists, it seems, began with their ‘usual’ practice and while remaining true to their ethos, modified that to fit the trial context and participants' needs. ...

Background Understanding intervention fidelity is an essential part of the evaluation of complex interventions because fidelity not only affects the validity of trial findings, but also because studies of fidelity can be used to identify barriers and facilitators to successful implementation, and so provide important information about factors likely to impact the uptake of the intervention into clinical practice. Participant observation methods have been identified as being particularly valuable in studies of fidelity, yet are rarely used. This study aimed to use these methods to explore the quality of implementation of a complex intervention (Safewards) on mental health wards during a cluster randomised controlled trial. Specific aims were firstly to describe the different ways in which the intervention was implemented, and secondly to explore the contextual factors moderating the quality of intervention delivery, in order to inform ‘real world’ implementation of the intervention. Methods Safewards was implemented on 16 mental health wards in England. We used Research Assistants (RAs) trained in participant observation to record qualitative observational data on the quality of intervention delivery (n = 565 observations). At the end of the trial, two focus groups were conducted with RAs, which were used to develop the coding framework. Data were analysed using thematic analysis. Results There was substantial variation in intervention delivery between wards. We observed modifications to the intervention which were both fidelity consistent and inconsistent, and could enhance or dilute the intervention effects. We used these data to develop a typology which describes the different ways in which the intervention was delivered. This typology could be used as a tool to collect qualitative observational data about fidelity during trials. Moderators of Safewards implementation included systemic, interpersonal, and individual factors and patient responses to the intervention. Conclusions Our study demonstrates how, with appropriate training in participant observation, RAs can collect high-quality observational data about the quality of intervention delivery during a trial, giving a more complete picture of ‘fidelity’ than measurements of adherence alone. Trial registration ISRCTN registry; IRSCTN38001825. Registered 29 August 2012 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2189-8) contains supplementary material, which is available to authorized users.

Introduction Policies internationally endorse the recovery paradigm as the appropriate foundation for youth mental health services. However, given that this paradigm is grounded in the views of adults with severe mental illness, applicability to youth services and relevance to young people is uncertain, particularly as little is known about young people’s views. A comprehensive understanding of the experiences and expectations of young people is critical to developing youth mental health services that are acceptable, accessible, effective and relevant. Aim To inform development of policy and youth services, the study described in this protocol aims to develop a comprehensive account of the experiences and expectations of 12–17 year olds as they encounter mental disorders and transition through specialist mental health services. Data will be analysed to model recovery from the adolescents’ perspective. Method and analysis This grounded theory study will use quantitative and qualitative data collected in interviews with 12–17 year olds engaged with specialist Child/Youth Mental Health Service in Queensland, Australia. Interviews will explore adolescents’ expectations and experiences of mental disorder, and of services, as they transition through specialist mental health services, including the meaning of their experiences and ideas of ‘recovery’ and how their experiences and expectations are shaped. Data collection and analysis will use grounded theory methods. Ethics and dissemination Adolescents’ experiences will be presented as a mid-range theory. The research will provide tangible recommendations for youth-focused mental health policy and practice. Findings will be disseminated within academic literature and beyond to participants, health professionals, mental health advocacy groups and policy and decision makers via publications, research summaries, conferences and workshops targeting different audiences. Ethical and research governance approvals have been obtained from relevant Human Research Ethics committees and all sites involved.

Collaborative inquiry involves a group of people in iterative examination of a shared experience, action to address identified concerns, and reflection. We describe our attempt to conduct a collaborative inquiry into the roles and experiences of health professionals designated as recovery champions within a mental health service. Our linked goals were to work with champions to support the desired shift in approach to care and implementation of recovery practices, and to gather data to develop our own understanding of the service culture. The inquiry opened up a communicative space in which robust discussion elucidated the complexities of implementing ‘recovery’ within a highly governed and scrutinised environment. Numerous problems and some opportunities for practice improvement were identified but with too little time and emotional space to engender group identity and work through ambiguity inherent in collaborative inquiry, no actions were implemented. However, champions came to appreciate substantial progress made and understand the service as one ‘in recovery’. They developed a sense of themselves as agents of change and agreed to continue the process independently. Review of the process sheds light on successes and limitations, drawing attention to the importance of context and realistic planning when considering such an inquiry.

Background: Strategies proposed to promote recruitment of representative samples to trials and mental health research have focused on researchers external to clinical services. How clinicians approach recruitment as researchers and particularities of recruiting people with first episode of psychosis warrant investigation.To describe recruitment, by clinicians, of people with first-episode psychosis (FEP) and factors influencing process and enrolment.Observational study nested within longitudinal examination of trauma and outcomes for patients experiencing first psychotic episode. Data collected during 20 scheduled meetings of clinicians recruiting from services in Australia.Timely recruitment of 60 young people demonstrates that clinicians can successfully engage patients in research. Success depends on satisfaction of organisational preconditions and clinician motivation grounded in considering the study worthwhile. Pre-selection of participants was informed by judgments about health, insight and quality of the therapeutic alliance. Patients' decisions were influenced by family support, acceptance of diagnosis and altruism. Honoraria had variable effect.Clinicians are well placed to recruit when appropriately supported, and people with FEP are willing to engage in research that fits their personal circumstances. Research should examine the meaning of participation in such studies and ways participation could support recovery.

UK guidelines recommend that patients with schizophrenia are offered access to social activities, however, the impact of such interventions have not been examined in a large randomized trial.To investigate the effect of an activity group intervention on mental health and global functioning 12 months after randomization compared to standard care alone.Secondary analysis of data from the MATISSE study. Primary outcomes were global functioning, assessed using the Global Assessment of Functioning (GAF), and mental health symptoms measured using the Positive and Negative Syndrome Scale (PANSS).About 140 participants were randomized to activity groups and 137 to standard care alone. Follow-up data were collected from 242 (87%) participants. Mental health improved significantly among those offered activity groups (change in PANSS score = -6.0, 95% CI -2.3 to -9.8) but global functioning did not (change in GAF score = 0.8, 95% CI -1.7 to 3.3). No significant differences were found between treatment arms.Offering activity groups to patients with schizophrenia was not associated with any additional clinical benefits. There was poor uptake and attendance at activity groups. Interventions that aim to improve negative symptoms may be useful in enabling engagement in psychosocial interventions.

Mental health nurses are in challenging positions. They have the opportunity to support people hospitalized for the treatment of mental illnesses on their recovery journeys, but are simultaneously required to manage a burgeoning administrative burden, maintain organizational 'order', and contain risk. While obliged by policy to engender an environment that promotes recovery, they receive little guidance about how this should be achieved. When feedback from people hospitalized in our service indicated the experience of care was variable, we undertook a pragmatic inquiry examining consumers' views about what makes an excellent mental health nurse. We interviewed 20 people with lived experience of hospitalization and analysed transcripts thematically. To ensure findings were relevant and useful, we consulted mental health nurses about nurses' needs, and incorporated this with the views of service users. The analysis demonstrated that personal qualities, professional skills, and environmental factors all influence the experience of mental health nursing. Our findings highlight a need for renewed attention to the basics of relationships and the importance for nurses of self-awareness and support. We urge nurses to make time to really get to know the people for whom they provide care, and to work to maintain passion for mental health nursing. It seems likely that attention to the simple things has the potential to improve levels of satisfaction among service users, decrease distress, and support the development of an environment in which can nurture recovery.

Schizophrenia is the name given to a debilitating condition treated medically with antipsychotic medication. However medication is only partially effective and many people diagnosed with schizophrenia have complex health and social needs requiring a spectrum of care which might include psychotherapy. Although National Institute for Clinical Excellence (NICE) guidelines for the treatment of schizophrenia state that referral to art therapy should be considered, especially for patients with negative symptoms, research supports the view that art therapy does not lead to improved patient outcomes when offered to most people with the disorder. Thus clinicians need more information to support consideration of referral. To this end, we report experiences of participants allocated to art therapy in a randomised trial of art therapy. By tracing the pathways and reported outcomes, we demonstrate that although relatively few ‘engaged’, those who did attributed personally valued changes, including improvement...

Enhancing choice and control for people using services is a mental health and social-care service priority in England. Personalisation is a new policy and practice for delivery of social-care services where eligible adults are allocated a personal budget to spend to meet their agreed support needs.To describe approaches to introducing personal budgets to people with severe and enduring mental health needs, and to identify facilitators or barriers encountered.Within four English local authority (LA) areas, purposively selected to provide maximum variation, semi-structured interviews were undertaken with 58 participants from LAs, NHS trusts and third-sector organisations. An Interpretive Framework analysis considered within- and across-site insights.Issues arising from the implementation of personalisation for people with mental health needs are presented under two general themes: "responsibility and power" and "vision and leadership". Key challenges identified were complexities of working across NHS and LAs, the importance of effective leadership and engagement with service user representatives.Implementing personal budgets in mental health requires effective engagement of health and social-care systems. Change processes need strong leadership, clear vision and personal commitment, with ownership by all key stakeholders, including front-line practitioners.

Social factors, health behaviours and the direct effects of substances contribute to the poor oral health and restricted access to dental services experienced by people who are dependent on drugs and/or alcohol. Admission for inpatient withdrawal management provides an opportunity for intervention to promote oral health but to be effective it must be acceptable to patients. To support intervention design, we examined patients' views about oral health, practices and treatment access, and appropriateness of health-promoting intervention in this context. Given paucity of knowledge in the area we employed a qualitative approach, data were collected in semi-structured interviews with inpatients of a public specialist alcohol and drug unit in Australia in September 2014. Analysis employed the framework approach. All 14 participants wanted 'good teeth' but few diligently attended to oral healthcare; most sought assistance only in emergencies. Participants' knowledge of services was limited and practical and affective barriers hindered access. With none recalling attention to oral health during admission, support was strong for incorporation of oral health in inpatient assessments. Participants wanted information about the impact of substances on oral health and oral hygiene practices provided in various formats, and facilitated referral to non-judgemental, affordable treatment. Patients regarded promotion of oral health in the inpatient context as important, relevant and acceptable. Support should respect the different knowledge, practices and motivations for oral health and recovery, of patients. Addressing practical and affective barriers to dental services will require collaboration between drug and alcohol and dental services, and this should be the focus of further research.

Background: Involvement of service users in mental health research, whether predicated on rights-based or instrumentalist arguments, is appropriately understood as a purposive social action likely to have both intended and unintended consequences. Despite rhetoric and some evidence that involvement is a good thing and confers benefits on the people involved, the impact on involved individuals remain underexplored.\ud \ud Aims: To describe the impact of involvement in research on views about mental health services and service use.\ud \ud Method: A cross-sectional survey of service users involved in mental health research across the UK. Data collected from 166 respondents using an online questionnaire were analysed using the framework approach and narratively synthesised.\ud \ud Results: Involvement, through enabling ‘behind the scenes’ access shaped views of service users about services and service use. Increased awareness of challenges and shortcomings of service delivery shifted expectations, commonly empowering service users to proactively engage in treatment. However, for some respondents, disillusionment led to discontinuation of services.\ud \ud Conclusions: Empowerment is a common outcome of involvement but a minority of service users may become critical and drop out of services. People considering involvement in research should be informed about the potential impact on their views and service use and be appropriately supported during involvement. The theory of user involvement needed to support robust examination of process and outcomes must encompass unintended consequences.

The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population of 550 000 people. Specifically, the ICP serves people older than 75 years and those with diabetes. Although still in the early stages of implementation, the ICP has already received national awards for its innovations in design and delivery. This article critically describes the ICP objectives, facilitating processes, and planned impact as well as the organizational and financial challenges that policy makers are facing in the implementation of the pilot program.

Aims: This study investigated the commissioning and delivery of advocacy for problem drug users. We aimed to quantify provision, describe the commissioning of advocacy services in Drug Action Teams (DATs) and to identify factors influencing advocacy provision.Methods: A cross-sectional survey of a randomly selected sample of 50 English DATs. The purpose-designed questionnaire comprising a mix of closed and open questions was completed through a telephone interview.Findings: An 86% response rate was achieved. Informants understood ‘advocacy’ as encompassing a range of activities including user involvement and peer support. A range of approaches classified as formal, informal and ad hoc were described. Whilst advocacy was identified as a need in 29 DATs (67%), formal, independent advocacy was commissioned in only four (9%). In eight DATs (19%), there was no advocacy provision of any kind.Conclusions: Advocacy is described by the National Treatment Agency as an essential element of effective drug treatment s...

Background. Little is known about service users’ views of measures used to evaluate treatments in mental health. Aims. To identify the views of people with psychosis and affective disorder about the relevance and acceptability of commonly used outcome measures. Methods. Twenty-four widely used outcome measures were presented to expert groups of service users. Nominal group methods were used to develop consensus about the appropriateness of each measure. Comments made by service users about how outcomes should be assessed were also recorded. Results. Group members expressed concern about the ability of some outcome measures to capture their experiences. Patient-rated measures were assessed as more relevant and appropriate than staffrated measures, and the need to examine negative as well as the positive effects of treatments was emphasised. Specific concerns were raised about some widely used measures including the Global Assessment of Functioning and the European Quality of Life scale. Conclusions. We consider it essential that service users’ views are taken into account when selecting measures to evaluate treatment outcomes. Providing insight into views of users of mental health services, our findings serve as a starting point for discussion.

External validity is central to pragmatic trials. Recruitment of a 'representative' sample is fundamental to this. However, recruitment is a complex process, requiring, first researcher access to eligible participants. Questions have been asked about the match between study samples and real-world clinical patients and the impact this has on generalisability of findings.Using interview and observational data from a grounded theory process evaluation of a multicentre trial, we investigated factors influencing referral.We found evidence of a fundamental disjunction between research and clinical practice manifested in varying 'filtering' processes. Organisational culture and the knowledge and attitudes of service providers regarding research generally and specifically in this RCT resulted in exclusion of very many potentially eligible participants.These findings have policy and practical implications and highlight the need for development of genuinely collaborative partnerships between the research and clinical communities. Importantly, we suggest that the CONSORT recommendations be further refined to identify the potential study population.

Aims: To investigate and describe the role of drug service user groups in local service user involvement (UI).Method: Mixed-method study involving cross-sectional survey of commissioners, providers and users of drug treatment services and qualitative in-depth case studies in samples of drug action teams in England.Findings: User groups experience problems with sustainability. While the majority of sites reported current or past involvement with user groups, active groups were identified in only a third of sites. These groups varied widely in form and function. Generally groups provided solidarity for users and access to expert opinion for agencies. There was evidence of conflict between user and agency expectations that was exacerbated by power imbalance, role ambiguity and inadequate infrastructure. While the transience of groups was viewed pragmatically by some, others perceived such problems as confirmation that people who use drugs are unable to form effective groups.Conclusions: User groups are funda...

Providers of public health care are under pressure to involve service-users in service development. This pressure emanates from legislators and the public who promote user involvement (UI), as a 'means to an end' and/or 'an end in itself'. Case studies in six English commissioning areas explored the process and purpose of UI in drug treatment services. In-depth interviews with 139 respondents who commission, manage, deliver or use services were conducted. We identified 'non-', 'passive-' and 'active participant' users. Active users were commonly motivated by a desire for social justice, a social conscience and personal development. UI was evidently influenced by multiple social organizational and personal factors. Some 'generic' factors have been reported in other settings. However, the illegality of drug use powerfully affects all stakeholders creating a context unique to drug treatment settings. Stigma and power imbalances were pervasive, and strong tensions concerning the goal and purpose of UI were apparent. Within the UK context, we identified five organizational approaches to UI. Based on rationale and objectives of UI, and the scope of influence accorded users, organizations could be characterised as protagonists, pragmatists, sceptics, abstainers or avoiders. We conclude that many tensions apparent in local level UI have roots in UI policy, which is ambiguous about: (1) benefit and rights, and (2) the promotion of healthcare objectives within a UK drug strategy driven by a crime reduction agenda. This duality must be resolved for UI to flourish at local level.

Aim: To examine the extent of user involvement (UI) in efforts to improve the quality of drug misuse services in England, to identify outcomes of involvement, and explore factors that promote and hinder this process. Methods: Cross-sectional survey of service commissioners, providers and members of user groups in a representative sample of 50 of the 149 English Drug Action Teams (DATs) in England. Findings: We found wide variation in the degree to which systems for involving users had been implemented. Thirty-nine (84.7%) of the 46 DATs that responded reported working with service users, but only 22 (47.8%) involved them directly in commissioning services. User groups had generally been set up with the support of service providers, and had been running for an average of three years. Most stakeholders were able to identify changes to the organization and delivery of services resulting from user involvement, but the impact of these changes on engagement and retention in services has not been examined. Stakeholders reported that cultural, organizational, and individual variables hindered UI, including staff resistance and limited numbers of users willing to be involved. Conclusions: Our findings suggest that most commissioners and providers of drug services in England involve users in efforts to improve service quality. Direct payments to users, effective systems for delivering feedback, and a better understanding of the impact of the outcomes of involvement may help to sustain this process.

Objective: We aimed to assess the feasibility of delivering a music therapy program on adolescent psychiatric wards. Method: We undertook a mixed-methods evaluation of a pilot program. Various active and receptive techniques were employed in group music therapy sessions delivered as part of a structured clinical program. Data collected in interviews with participants and staff and feedback questionnaires were thematically and descriptively analysed and triangulated. Results: Data from 62 questionnaires returned by 43 patients who took part in 16 music therapy sessions, and seven staff, evidenced strong support for music therapy. Patients typically reported experiencing sessions as relaxing, comforting, uplifting, and empowering; >90% would participate by choice and use music therapeutically in the future. Staff endorsed music therapy as valuable therapeutically, reporting that patients engaged enthusiastically and identified sessions as improving their own moods and ward milieu. Conclusions: Integration of music therapy in inpatient treatment of adolescents is feasible and acceptable, and is valued by staff and patients as a complement to ‘talking therapies’. Participation is enjoyed and associated with outcomes including improvement in mood, expression of feelings and social engagement consistent with recovery.

Objective: To describe the prevalence and demographic, clinical and functional correlates of childhood trauma in patients attending early psychosis clinics. Method: Participants were recruited from outpatients attending four early psychosis services. Exposure to childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Psychopathology was measured using the Positive and Negative Syndrome Scale and the Depression, Anxiety and Stress Scale. Social and vocational functioning and substance use were also assessed. Results: Over three-quarters of the 100 patients reported exposure to any childhood trauma. Emotional, physical and sexual abuse were reported by 54%, 23% and 28% of patients, respectively, while 49% and 42% of patients reported emotional and physical neglect, respectively. Female participants were significantly more likely to be exposed to emotional and sexual abuse. Exposure to childhood trauma was correlated with positive psychotic symptoms and higher levels of depressive, anxiety and stress symptoms; however, it had no impact on social or vocational functioning or recent substance use. Conclusion: Exposure to childhood trauma was common in patients with early psychosis, and associated with increased symptomatology. Existing recommendations that standard clinical assessment of patients with early psychosis should include inquiry into exposure to childhood trauma are supported.

Objective: To describe completeness and accuracy of recording medication changes in progress notes during psychiatric inpatient admissions. Method: A retrospective audit of records of 54 randomly selected psychiatric admissions at a metropolitan tertiary hospital. Medication changes recorded on National Inpatient Medication Chart (NIMC) were compared to documentation in the clinical progress records and assessed for completeness against seven quality criteria. Results: With between one and 32 medication changes per admission, a total of 519 changes were recorded in NIMCs. Just over half were documented in progress notes. Psychotropic and regular medications were more frequently charted than ‘other’ and ‘if required’ medications. Documentation was seldom comprehensive. Medication name was most frequently documented; desired therapeutic effect or potential adverse effects were rarely documented. Evidence of patient involvement in, and an explicit rationale for, a change were infrequently recorded. Conclusions: Revealing substantial gaps in communication about medication changes during psychiatric admission, this audit sheds light on a previously undescribed source of medication error, warranting attention. Further research is needed to examine barriers to best practice, to support design and implementation of quality improvement activities but in the interim, attention should be addressed to development and articulation of content and procedures for documentation.

Anorexia nervosa (AN) is an extremely serious mental illness, with a high mortality rate and many debilitating physical and psychological symptoms. While hospitalisation is sometimes required for patients with AN there remains no evidence base for “best practice’ inpatient treatment. With patients’ views recognised as critical to improving efficiency and outcomes, calls have been made for more qualitative research into inpatients’ experiences. In light of this the current paper utilised thematic analysis to examine 16 semi-structured interviews with inpatients diagnosed with AN, at a specialised eating disorders hospital unit. The study found an overarching theme of relationship ambivalence in connection with sub-themes of patients’ eating disorders, eating disorder co-patients, staff and treatment. Participants’ goals in relationship to their eating disorder and engagement in treatment shaped and were shaped by interactions with other inpatients with AN and staff. Clinical implications for this study and future research directions are discussed.

BackgroundOptimisation of the process and outcomes of service user involvement in research is dependent on understanding current practice, challenges and opportunities.AimsTo describe activities, roles and experiences of service users involved in mental health research.MethodNational cross-sectional online questionnaire survey, using snowball sampling. Descriptive statistics and framework analysis undertaken collaboratively with a service user reference group.ResultsThe survey revealed a previously undescribed, highly qualified service user research workforce. Positioned within and alongside mainstream research, respondents reported drawing on extensive service use, and passion for service improvement to challenge perceived clinical academic dominance of research. The support of peers was crucial to involvement, which typically enhanced mental health but for some, pervasive stigma and scrutiny undermined self-confidence and practical difficulties challenged equitable participation.ConclusionsRecognition of the service user research workforce will support the constructive amalgamation of academic and experiential expertise needed to shape and realise investment in mental health research.

Background: Recruitment to trials is complex and often protracted; selection bias may compromise generalisability. In the mental health field (as elsewhere), diverse factors have been described as hindering researcher access to potential participants and various strategies have been proposed to overcome barriers. However, the extent to which various influences identified in the literature are operational across mental health settings in England has not been systematically examined.\ud \ud Methods: A cross-sectional, online survey of clinical studies officers employed by the Mental Health Research Network in England to recruit to trials from National Health Service mental health services. The bespoke questionnaire invited participants to report exposure to specified influences on recruitment, the perceived impact of these on access to potential participants, and to describe additional positive or negative influences on recruitment. Analysis employed descriptive statistics, the framework approach and triangulation of data.\ud \ud Results: Questionnaires were returned by 98 (58%) of 170 clinical studies officers who reported diverse experience. Data demonstrated a disjunction between policy and practice. While the particulars of trial design and various marketing and dommunication strategies could influence recruitment, consensus was that the culture of NHS mental health services is not donducive to research. Since financial rewards for recruitment paid to Trusts and feedback about studies seldom reaching frontline services, clinicians were described as distanced from research. Facing continual service change and demanding clinical workloads, clinicians generally did not prioritise recruitment activities. Incentives to trial participants had variable impact on access but recruitment could be enhanced by engagement of senior investigators and integrating referral with routine practice. Comprehensive, robust feasibility studies and reciprocity\ud between researchers and clinicians were considered crucial to successful recruitment.\ud \ud Conclusions: In the mental health context, researcher access to potential trial participants is multiply influenced. Gatekeeping clinicians are faced with competing priorities and resources constrain research activity. It seems that environmental adjustment predicated on equitable resource allocation is needed if clinicians in NHS mental health services are to fully support the conduct of randomised controlled trials. Whilst cultural transformation, requiring changes in assumptions and values, is complex, our findings suggest that attention to practical matters can support this and highlight issues requiring careful consideration.

Copyright @ 2014 Froud et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Background - Low back pain (LBP) is a common and costly problem that many interpret within a biopsychosocial model. There is renewed concern that core-sets of outcome measures do not capture what is important. To inform debate about the coverage of back pain outcome measure core-sets, and to suggest areas worthy of exploration within healthcare consultations, we have synthesised the qualitative literature on the impact of low back pain on people’s lives. Methods - Two reviewers searched CINAHL, Embase, PsycINFO, PEDro, and Medline, identifying qualitative studies of people’s experiences of non-specific LBP. Abstracted data were thematic coded and synthesised using a meta-ethnographic, and a meta-narrative approach. Results - We included 49 papers describing 42 studies. Patients are concerned with engagement in meaningful activities; but they also want to be believed and have their experiences and identity, as someone ‘doing battle’ with pain, validated. Patients seek diagnosis, treatment, and cure, but also reassurance of the absence of pathology. Some struggle to meet social expectations and obligations. When these are achieved, the credibility of their pain/disability claims can be jeopardised. Others withdraw, fearful of disapproval, or unable or unwilling to accommodate social demands. Patients generally seek to regain their pre-pain levels of health, and physical and emotional stability. After time, this can be perceived to become unrealistic and some adjust their expectations accordingly. Conclusions - The social component of the biopsychosocial model is not well represented in current core-sets of outcome measures. Clinicians should appreciate that the broader impact of low back pain includes social factors; this may be crucial to improving patients’ experiences of health care. Researchers should consider social factors to help develop a portfolio of more relevant outcome measures. Arthritis Research UK

Whilst most treatment for eating disorders occurs in an outpatient setting, inpatient treatment and care can play an important role if a patient is medically unstable, or is not responding to outpatient or day program treatments. With limited research conducted to date, the effectiveness of inpatient care and the role it plays in promoting recovery remain incompletely elucidated.

Introduction: Multidisciplinary Group meeting (MDGs) are seen as key facilitators of integration, moving from individual to multi-disciplinary decision making, and from a focus on individual patients to a focus on patient groups. We have developed a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot. Methods: We defined 'integrating' as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from communication, group decision-making, and integrated care literatures - the Valence, the Focus, and the Level. Standardized weighted integrative intensity scores are calculated across ten time deciles in the Case Discussion providing a graphical representation of its integrative intensity.Results: Intra- and Inter-rater reliability of the coding scheme was very good as measured by the Prevalence and Bias-adjusted Kappa Score. Standardized Weighted Integrative Intensity graph mirrored closely the verbatim transcript and is a convenient representation of complex communication dynamics. Trend in integrative intensity can be calculated and the characteristics of the MDG can be pragmatically described.Conclusion: This is a novel and potentially useful method for researchers, managers and practitioners to better understand MDG dynamics and to identify whether participants are integrating. The degree to which participants use MDG meetings to develop an integrated way of working is likely to require management, leadership and shared values.

OBJECTIVE: To examine the clinical effectiveness and cost-effectiveness of referral to group art therapy plus standard care, compared with referral to an activity group plus standard care and standard care alone, among people with schizophrenia. DESIGN: A three-arm, parallel group, single-blind, pragmatic, randomised controlled trial. Participants were randomised via an independent and remote telephone randomisation service using permuted blocks, stratified by study centre. SETTING: Study participants were recruited from secondary care mental health and social services in four UK centres. PARTICIPANTS: Potential participants were aged 18 years or over, had a clinical diagnosis of schizophrenia, confirmed by an examination of case notes, and provided written informed consent. We excluded those who were unable to speak sufficient English to complete the baseline assessment, those with severe cognitive impairment and those already receiving arts therapy. INTERVENTIONS: Group art therapy was delivered by registered art therapists according to nationally agreed standards. Groups had up to eight members, lasted for 90 minutes and ran for 12 months. Members were given access to a range of art materials and encouraged to use these to express themselves freely. Activity groups were designed to control for the non-specific effects of group art therapy. Group facilitators offered various activities and encouraged participants to collectively select those they wanted to pursue. Standard care involved follow-up from secondary care mental health services and the option of referral to other services, except arts therapies, as required. MAIN OUTCOME MEASURES: Our co-primary outcomes were global functioning (measured using the Global Assessment of Functioning Scale - GAF) and mental health symptoms (measured using the Positive and Negative Syndrome Scale - PANSS) at 24 months. The main secondary outcomes were level of group attendance, social functioning, well-being, health-related quality of life, service utilisation and other costs measured 12 and 24 months after randomisation. RESULTS: Four hundred and seventeen people were recruited, of whom 355 (85%) were followed up at 2 years. Eighty-six (61%) of those randomised to art therapy and 73 (52%) of those randomised to activity groups attended at least one group. No differences in primary outcomes were found between the three study arms. The adjusted mean difference between art therapy and standard care at 24 months was -0.9 [95% confidence interval (CI) -3.8 to 2.1] on the GAF Scale and 0.7 (95% CI -3.1 to 4.6) on the PANSS Scale. Differences in secondary outcomes were not found, except that those referred to an activity group had fewer positive symptoms of schizophrenia at 24 months than those randomised to art therapy. Secondary analysis indicated that attendance at art therapy groups was not associated with improvements in global functioning or mental health. Although the total cost of the art therapy group was lower than the cost of the two comparison groups, referral to group art therapy did not appear to provide a cost-effective use of resources. CONCLUSIONS: Referring people with established schizophrenia to group art therapy as delivered in this randomised trial does not appear to improve global functioning or mental health of patients or provide a more cost-effective use of resources than standard care alone. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 46150447. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 8. See the HTA programme website for further project information.

OBJECTIVES: To evaluate the clinical effectiveness of group art therapy for people with schizophrenia and to test whether any benefits exceed those of an active control treatment.DESIGN: Three arm, rater blinded, pragmatic, randomised controlled trial.SETTING: Secondary care services across 15 sites in the United Kingdom.PARTICIPANTS: 417 people aged 18 or over, who had a diagnosis of schizophrenia and provided written informed consent to take part in the study.INTERVENTIONS: Participants, stratified by site, were randomised to 12 months of weekly group art therapy plus standard care, 12 months of weekly activity groups plus standard care, or standard care alone. Art therapy and activity groups had up to eight members and lasted for 90 minutes. In art therapy, members were given access to a range of art materials and encouraged to use these to express themselves freely. Members of activity groups were offered various activities that did not involve use of art or craft materials and were encouraged to collectively select those they wanted to pursue.MAIN OUTCOME MEASURES: The primary outcomes were global functioning, measured using the global assessment of functioning scale, and mental health symptoms, measured using the positive and negative syndrome scale, 24 months after randomisation. Main secondary outcomes were levels of group attendance, social functioning, and satisfaction with care at 12 and 24 months.RESULTS: 417 participants were assigned to either art therapy (n=140), activity groups (n=140), or standard care alone (n=137). Primary outcomes between the three study arms did not differ. The adjusted mean difference between art therapy and standard care at 24 months on the global assessment of functioning scale was -0.9 (95% confidence interval -3.8 to 2.1), and on the positive and negative syndrome scale was 0.7 (-3.1 to 4.6). Secondary outcomes did not differ between those referred to art therapy or those referred to standard care at 12 or 24 months.CONCLUSIONS: Referring people with established schizophrenia to group art therapy as delivered in this trial did not improve global functioning, mental health, or other health related outcomes.TRIAL REGISTRATION: Current Controlled Trials ISRCTN46150447.

Art therapy has been recommended as a treatment for people with psychosis. However, little is known about the availability, organisation or delivery of art therapy within NHS settings.To describe the availability, structure and content of art therapy for people with schizophrenia provided by NHS services in England.A survey of art therapists working in a randomly selected sample of half of all mental health Trusts in England.Not all mental health Trusts employ art therapists. Those which do employ few therapists, typically on a sessional basis who work across a variety of inpatient and community-based settings. Most art therapists report that their practice is underpinned by psychodynamically grounded understandings of psychosis. However, rather than seek to explore underlying dynamics, art therapists typically adopt a non-directive approach encouraging patients to use image making to express feelings and reflect on these in a concrete way to develop self-understanding. While three-quarters of respondents reported that their work was valued by colleagues, less than half considered art therapy well understood by colleagues or integrated with other services.People diagnosed with schizophrenia have limited access to art therapy in NHS settings. Further research is needed to understand the experience and outcomes of art therapy to support its meaningful integration within the spectrum of care required to meet the needs of people with schizophrenia.