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Background: Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs., Methods: We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1-3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies., Discussion: The study's key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery., Competing Interests: The authors have declared that no competing interests exist. The study was commissioned by Wirral Clinical Commissioning Group and routed through Cheshire and Wirral Partnership NHS Foundation Trust (CWP) to Liverpool John Moores University. TN and AS are employed by CWP and work for the health organisation where the study is taking place. No other relationships or activities could appear to have influenced the submitted work. The funding commissioners had no role in the design of the study; in the collection, analyses, or interpretation of data; or in the writing of the manuscript.

Background: NHS England's Transforming Care agenda aims to reduce the number of adults with intellectual disabilities and autistic adults in mental health hospitals. The aim was to understand the demographic and clinical characteristics of those most at risk of admission. Method: A cohort, retrospective study of adults using community intellectual disability services in the North West of England from 2018 to 2022 was undertaken. Results: We compared 211 adults at imminent risk of admission to a mental health hospital and 249 at significant (but not imminent) risk on a validated risk stratification tool. Individuals at significant risk were more likely to have moderate intellectual disability. Individuals at imminent risk were more likely to have diagnoses of mild intellectual disability, autism, personality disorder, or psychosis. Conclusion: By furthering our understanding of the clinical characteristics of those most at risk of admission, the findings inform more appropriate targeting of resources. [ABSTRACT FROM AUTHOR]

Accessible Summary: What the paper adds to existing knowledge?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without.Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self‐harm and suicidal behaviours.Staff burnout creates barriers to compassionate person‐centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. What are the implications for practice?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users.A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes. Introduction: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out‐of‐area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high‐quality care. Aim: To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out‐of‐area placements. Method: Semi‐structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed. Results: Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD. Discussion: Anti‐stigma interventions for staff, research on care provision and structural changes to services including more evidence‐based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery. Implications for Practice: This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The Dynamic Appraisal of Situational Aggression (DASA) provides a quick and systematic assessment of short-term violence risk. Risk assessment should be closely aligned to management and result in interventions aimed to reduce risk. The aim of this study was to investigate what interventions followed a moderate/high DASA score and whether they reduced risk. The impact of staff training was also assessed. The study was a retrospective analysis of health records within a medium secure hospital over 6 months. Data was gathered on tool adherence and interventions that were used to reduce risk following a moderate/high score. The change in DASA score following the intervention was recorded. There were 70 patients covering 8224 bed days. There were 24 occasions where a moderate score led to an intervention (n = 24/40%), and 26 occasions for a high score (n = 26/87%). A moderate score was mostly followed by no intervention (n = 35/59%), a high score was mostly followed by seclusion (n = 9/29%). The intervention that led to the largest reduction in DASA score was pro re nata medication following a moderate score and seclusion following a high score. The training of staff led to a reduction in tool adherence and increased intervention use. These results support the need for combining the DASA assessment with operationalised systems to link assessment with risk prevention to help reduce aggression and restrictive practices. [ABSTRACT FROM AUTHOR]

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18–24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18–24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services. [ABSTRACT FROM AUTHOR]

In everyday mental health practice, clinicians are expected to assess and manage the risk of harm that may be caused by their patients to others. An informed approach to the activities of risk assessment and management should be grounded in a thorough understanding of the notion of risk. Whilst there are agreed definitions of risk, they do not do justice to the complexity of in-vivo representations of risk. Based on a review of the literature, an analysis of clinical guidelines, and practicing psychiatrists' reflections on their own clinical experiences and sample vignettes, this article explores the varied subjective representations of risk in mental health practice. Of specific relevance to the possibility of an individual causing harm is the need to recognise that the causal agent of harm is an as-yet-unrealised state of consciousness, and that actions that may reduce risk are multiple and have effects that are difficult to define in advance. From an analysis of the semantic context of the use of the word 'risk' within practice guidance, the authors demonstrate a wide range of meanings (including harm, possibility of harm, characteristics of possible harm, a state with changeable potential for harm, and different states of potential harm) with different degrees of embodiment. With reference to clinical scenarios, the formation of individual subjective representations of risk are shown to vary not only in the way they can be characterised (e.g. likelihood, severity, and imminence), but also in the extent to which they come into subjective focus. Uncovering the different ways risk is represented in practice should allow a more refined approach to guiding and studying the process of risk assessment and management. [ABSTRACT FROM AUTHOR]

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear. Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions. Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis. Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors. Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models. [ABSTRACT FROM AUTHOR]

SUMMARY: Substance misuse worsens the prognosis for people suffering psychosis and places them at risk of being denied appropriate mental health service interventions. To increase the chances of its success, the plan of management for patients with coexisting psychosis and substance misuse should be based on a valid formulation of their problems, which in turn is dependent on the clinician having (a) a thorough understanding of the bidirectional and changing ways that substance use and mental illness symptoms can interact, (b) an awareness of their own biased implicit assumptions about causality in explaining these interactions and (c) a framework for assessment and formulation. This article addresses these three areas with reference to the evidence base and to clinical experience in a way that guides mental health clinicians in the assessment of patients with coexisting psychosis and substance misuse. [ABSTRACT FROM AUTHOR]

Background: High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services.Aim: To examine the social determinants of health service use in people with mental health issues.Design and Setting: Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation.Method: A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors.Results: Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38).Conclusion: Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed. [ABSTRACT FROM AUTHOR]

A work environment characterized by frequent emotionally-charged interactions increases the risk of staff burnout. It was hypothesized that gender differences in psychopathology in forensic mental health settings may be associated with differences in the risk of burnout. The development of single-sex accommodation in a medium secure facility provided an opportunity to examine the impact of such patient gender differences within a therapeutic setting. In this study, nurses allocated to work on a new women's ward were assessed for burnout before the ward opened and a subgroup was re-assessed 18 months later. A comparison group of nurses working on a men's ward were assessed at the same two time points. Nurses working on the women's ward experienced a significantly greater increase in the emotional exhaustion component of burnout. There was some indication of a similar process for the depersonalization component. The implications of these findings are discussed in the context of the literature relating to the psychopathological and interpersonal differences between male and female patients and relating to the responses of clinicians to these differences. [ABSTRACT FROM AUTHOR]