Search

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the 'responsiveness of expenditure to need' and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Objectives: In recent times, the world has witnessed unprecedented challenges, with the COVID-19 pandemic being a major disruptor to various aspects of daily life. This article delves into the profound impact of pandemics on primary care, specifically focussing on changes in antidepressant prescriptions and mental health referrals before, during, and after lockdowns in England, UK., Methods: In this retrospective study, we used anonymised individual-level electronic health record data from general practitioner (GP) practices in the North of England, UK. We applied a negative binomial-logit hurdle model and a multinominal logit regression model to assess the impact on antidepressant prescriptions and GP referral types, respectively., Results: The initiation of antidepressant prescriptions showed a notable decrease during and post lockdowns, with a minor uptick in ongoing antidepressant prescriptions during the lockdown periods. Over the course of lockdowns and beyond, there was a growing trend of patients being referred to social prescribing interventions. Notably, individuals from ethnic minorities were more inclined to receive fewer medical treatments and more social prescribing interventions., Conclusion: The increase in antidepressant prescriptions during the pandemic-related lockdowns was expected due to these challenging circumstances. Reduced referrals to secondary mental health services occurred as online counselling services were deemed inappropriate by some doctors, and patients were hesitant to seek face-to-face help. Notably, there was a rise in social prescribing referrals, emerging as a valuable resource for psychological support amid heightened mental health strain. Additionally, ethnic minority patients were less likely to receive medical treatments but more likely to be referred to social prescribing services. Despite the inevitable negative impacts of the COVID-19 pandemic, these findings highlight the active role of non-clinical support in a social model of health, addressing unmet needs and reducing barriers to mental health care for certain groups., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: This study aims to examine the proportions of patients referred to mental health, social and voluntary, community and social enterprise (VCSE) services and general practice and to assess care gaps among people presenting to the hospital following self-harm., Design: Population-based observational study. Data were extracted from hospital records., Setting: Three emergency departments (EDs) in Manchester, UK., Participants: 26 090 patients aged 15+ years who presented to participating EDs following self-harm and who received a psychosocial assessment by a mental health specialist., Primary and Secondary Outcome Measures: Primary outcome measures are as follows: care gaps, estimated from the proportion of patients with evidence of social and mental health needs with no new or active referral to mental health, social and VCSE services. Secondary outcome measures are as follows: proportions of referrals by groups of patients, estimated mental health and social needs of patients. Indicators of mental health and social need were developed with academic clinicians (psychiatrist, general practitioner and social worker) and expert lived experience contributors., Results: 96.2% (25 893/26 909) of individuals were estimated as having mental health needs. Among this group, 29.9% (6503/21 719) had no new or active referral to mental health services (indicating a care gap). Mental healthcare gaps were greater in men and those who were aged under 35 years, from a black, South Asian or Chinese ethnic group, living in the most deprived areas and had no mental health diagnosis, or alcohol, substance misuse, anxiety or trauma-related disorder. 52.8% (14 219/26 909) had social needs, with care gaps greater for men, individuals aged 45-64 and those who were unemployed or had a diagnosed mental disorder., Conclusions: Care gaps were higher among hospital-presenting groups known to have increased risks of suicide: men, those in middle age, unemployed individuals and those misusing substances. Improved access to mental health, social and VCSE services and general practice care is vital to reduce inequities in access to self-harm aftercare., Competing Interests: Competing interests: NK reports research grants and fees to related his research and implementation work in self-harm and suicide prevention from the Department of Health and Social Care, the National Institute for Health and Care Research, the Healthcare Quality Improvement Partnership and the National Institute for Health and Care Excellence (NICE). NK does not receive industry funding for research. NK is a member of England's National Suicide Prevention Strategy Advisory Group and is supported by Mersey Care NHS Foundation Trust. NK chaired the NICE guideline development group for the NICE depression in adults' guideline and was a topic expert member for the NICE suicide prevention guideline. NK chaired the guideline development group for the NICE guidelines on the longer-term management of self-harm and was a topic advisor on the 2022 NICE guideline on self-harm. FM was a member of the 2022 NICE guideline development committee. The other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

WHAT IS KNOWN ON THE SUBJECT?: Mental health services report adverse incidents in different ways and the relationship between adverse incidents and the workforce is uncertain. In England, there are national datasets recording all incidents and workforce statistics though there is no peer-reviewed evidence examining recent trends. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Although there has been an overall increase in the number of mental health nurses, more are working in the community and the number of nurses relative to adverse incidents has decreased. There have been service-provision changes but the role of mental health nurses has not significantly changed in this period, and we can therefore assume that their current practice is saturated with risk or increased reporting. To help understand the relationship between nurses and incidents, we need to transform how incidents are recorded in England. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: English mental health services report greater levels of patient-related factors such as self-harm or aggression rather than missed or erroneous care. This makes it difficult to understand if a rise in incident frequency is linked to reporting behaviour, patient risk, unsafe/ineffective care or other reasons and therefore planning workforce deployment to improve care quality is problematic., Abstract: INTRODUCTION: There is a paucity of empirical data examining incidents and mental health nurses and the relationship between the two remains uncertain., Aim: Comparison of English national data for incidents and nursing workforce to examine recent trends., Method: Descriptive analysis of two national datasets of incidents and workforce data for England between 2015 and 2022., Results: A 46% increase in incidents was found; the leading causes are self-harm and aggressive behaviour. Despite the rise in adverse incident reporting, a 6% increase in mental health nurses was found, with more nurses in community settings than hospitals., Discussion: Current services are incident reporting at greater concentrations than in previous years. Patient-related behaviour continues to be most prominently reported, rather than possible antecedent health services issues that may contribute to reporting. Whilst staffing has increased, this does not seem to have kept pace with the implied workload evident in the increase in incident reports., Implications for Practice: Greater emphasis should be placed on health service behaviour in reporting mechanisms. Self-harm and aggression should continue to be considered adverse outcomes, but causal health service factors, such as missed care, should be present in pooled reporting to help reduce the occurrence of adverse outcomes., (© 2024 The Authors. Journal of Psychiatric and Mental Health Nursing published by John Wiley & Sons Ltd.)

Background: Major depressive disorder (MDD) is a disabling mental illness that can affect all aspects of daily life and is a leading cause of healthcare resource utilisation (HCRU)., Aims: We aimed to characterise patients with MDD with moderate-to-high-suicide-intent, compare their HCRU to patients with MDD without moderate-to-high-suicide-intent, and better understand their patient pathways., Methods: This retrospective cohort study used data collected from primary care electronic health records from Clinical Practice Research Datalink (CPRD), linked to Hospital Episode Statistics, Mental Health Services Data Set, and Office for National Statistics in England. Adults diagnosed with ≥ 1 MDD diagnosis between 04/2007 and 11/2015 were categorised by suicide intent., Results: 307,476 patients with MDD were included (294,259 patients without moderate-to-high-suicide-intent and 13,217 with moderate-to-high-suicide-intent). Patients with MDD with moderate-to-high-suicide-intent were younger on average (39.0 vs. 44.8 years) and included a lower percentage of females (58% vs. 65%) compared to patients without moderate-to-high-suicide-intent. HCRU was greater among patients with moderate-to-high-suicide-intent than patients without moderate-to-high-suicide-intent during the first follow-up year for general practitioner consultations (38.5 vs. 29.4), psychiatric outpatient visits (1.5 vs. 0.1), psychiatrist visits (3.6 vs. 0.3), emergency visits (1.5 vs. 0.3), and hospitalisations (86% vs. 26%). Overall, 56% of patients with moderate-to-high-suicide-intent had an antidepressant prescription within 30 days from the initial moderate-to-high-suicide-intent., Conclusions: Patients with MDD and moderate-to-high-suicide-intent were younger, included more males and incurred greater HCRU than those without moderate-to-high-suicide-intent. These results suggest a greater need for effective medical care and appropriate treatments for patients with moderate-to-high-suicide-intent, which could help reduce associated symptoms, mortality, and HCRU., (© 2024. The Author(s).)

Background: Although studies have suggested a high risk of suicide in people with eating disorders, most studies have focused on suicidal ideation and attempts. There is little research on the characteristics of people with eating disorders who died by suicide, nor investigation of trends over time. We aimed to compare the characteristics of patients with eating disorders who died by suicide versus patients with other mental health diagnoses who died by suicide in England and to examine the trends in rates., Methods: In this national retrospective cohort study, data on all people (aged ≥10 years) who died by suicide in England, UK, between Jan 1, 1997, and Dec 31, 2021, while under the care (within the previous 12 months) of mental health services were obtained from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), in which clinical information is collected via a questionnaire completed by the mental health professional responsible for the patient's care. Incidence of suicide in, and demographic, clinical, and treatment characteristics of, patients with a diagnosis of eating disorder (as recorded by the treating clinician) who died by suicide were compared with patients with other mental health diagnoses who died by suicide within the same timeframe using univariable logistic regression analysis. People with related lived experience were involved in the study design, implementation, interpretation, and writing of the manuscript., Findings: Of 119 446 people for whom NCISH were notified of dying by suicide in England, 30 795 were under the recent care of mental health services, of whom 30 246 had known diagnoses and were included in analyses. Of these individuals, 10 373 (34%) were female and 19 873 (66%) were male; 2236 (8%) were of minority ethnicity; 382 (1%) had a diagnosis of eating disorder and 29 864 (99%) had another mental health diagnosis. Compared with patients with other mental health diagnoses who died by suicide, patients with eating disorders were younger (median age 33 years [range 15-90] vs 45 years [10-100]), more often female (343 [90%] female and 39 [10%] male in the eating disorders group; 10 030 [34%] female and 19 834 [66%] male in the other diagnoses group), and less likely to have evidence of conventional risk factors for suicide such as living alone (odds ratio [OR] 0·68, 95% CI 0·55-0·84). 22 (6%) of 382 were from a minority ethnic group. Patients with an eating disorder were characterised by a greater clinical complexity (eg, self-harm [OR 2·31, 95% CI 1·78-3·00], comorbidity [9·79, 6·81-14·1], and longer duration of illness [1·95, 1·56-2·43]), and were more likely to have died following overdoses (2·00, 1·62-2·45) than patients with other diagnoses. Childhood abuse (52 [37%] of 140) and domestic violence (18 [20%] of 91) were common in patients with eating disorders. Similar to patients with other diagnoses, most (244 [75%] of 326) of those with eating disorders who died by suicide were rated as low risk by clinicians at last contact. The number of suicide deaths in patients with eating disorders rose between 1997 and 2021 (incidence rate ratio [IRR] 1·03, 95% CI 1·02-1·05; p<0·0001), but rates fell when accounting for the greater number of patients entering mental health services (IRR 0·97, 0·95-1·00; p=0·033)., Interpretation: This study was focused on people who sought help from mental health services. It did not consider subtypes of eating disorders or include a control group, but it does highlight possible areas for intervention. The comprehensive provision of evidence-based treatment for eating disorders and underlying conditions to address the clinical complexity in these patients might help to reduce suicide. Recognising limitations in clinical risk assessment, addressing early life experiences and current adversities, and appropriate prescribing might also be of benefit. Suicide prevention must remain a priority for eating disorder services and mental health care more widely., Funding: The Healthcare Quality Improvement Partnership., Competing Interests: Declaration of interests NK works with NHS England on national quality-improvement initiatives for suicide and self-harm; is on the Department of Health and Social Care (DHSC) National Suicide Prevention Strategy Advisory Group for England; chaired the guideline development group for the 2012 UK National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm; chaired the guideline development group for the 2022 NICE guideline on depression in adults; and was a topic advisor for the 2022 NICE guideline Self-Harm: Assessment, Management and Preventing Recurrence. LA is Chair of the DHSC National Suicide Prevention Strategy Advisory Group. NK, LA, and PT report grants from the Healthcare Quality Improvement Partnership, NHS England, the Department for Education, and the Medical Research Council. PT reports a grant from the Gambling Research Exchange Ontario. All other authors declare no competing interests., (Copyright Crown Copyright © 2024 Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Objectives: People living in less urban areas in the UK may have reduced access to mental healthcare compared with people in urban areas. Although this was not reported in the 2000 Adult Psychiatric Morbidity Survey (APMS) data, subsequent changes to mental health provision and economic recession may have impacted care inequalities. We re-examined this, hypothesising that those living in less urban areas of England received less antidepressant medication and psychological interventions, compared with those living in urban areas, after adjusting for covariates including common mental disorders (CMDs) and socioeconomic status., Design: National cross-sectional study., Setting: Households in England., Participants: We analysed data from 7455 participants aged 16 and above from the 2014 English APMS., Exposures: Residence in an urban or less urban area., Primary Outcome: Current receipt of any antidepressant medication or any psychological intervention., Results: Participants living in less urban areas were half as likely to be in receipt of any psychological intervention relative to those living in urban areas (adjusted OR (aOR) 0.49; 95% CI 0.30 to 0.79; p=0.004). There was no association between urbanisation and antidepressant receipt (aOR 1.01; 95% CI 0.81 to 1.25; p=0.944)., Conclusion: People living in less urban areas have a lower likelihood of being in receipt of psychological treatment for CMDs, which may indicate barriers to care access. Our findings differ from the results of a study using a comparable sample conducted 14 years previously. While Improving Access to Psychological Therapies services have increased therapy access nationwide, this may have had more impact in urban areas, potentially widening urban/rural inequalities. Further research is needed to understand how to address such geographical inequalities in access to mental healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach. We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents. Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (-110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed. Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region., Competing Interests: Declaration of competing interest We declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission., Methods: Data from the 2010-2011 Mental Health Minimum Dataset ( N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density., Results: Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission., Conclusions: We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Competing Interests: Competing interests: none declared

Competing Interests: I declare no competing interests.

Objective: This study aimed to explore the effects of COVID-19 and the lockdown measures adopted in England on patients with acute mental illness., Methods: The authors analyzed referrals to the crisis resolution and home treatment (CRHT) team and inpatient admissions to acute adult wards, at Leicestershire Partnership National Health Service Trust, an integrated community and mental health trust in the United Kingdom. Number of CRHT referrals and inpatient admissions during a 4-week period starting March 16, 2020 ("COVID-19 period"), was studied and compared with the same period in 2018 and 2019 ("control periods"). Demographic and clinical characteristics of patients admitted during the COVID-19 period were compared with those admitted during the 2019 control period., Results: The number of CRHT referrals and inpatient admissions were lower during the COVID-19 period, compared with the control periods, by approximately 12% and 20%, respectively. Patients admitted during the COVID-19 period were significantly more often detained under the Mental Health Act and were considered to pose a risk of aggression. The pattern of diagnoses differed significantly between 2020 and 2019. A higher percentage of patients admitted during the COVID-19 period were diagnosed as having nonaffective psychotic disorders (52% versus 35%) or bipolar disorder (25% versus 15%), and fewer received a diagnosis of depression (8% versus 16%), anxiety disorder (0% versus 3%), adjustment disorder (0% versus 8%), emotionally unstable personality disorder (6% versus 15%), or any other personality disorder (0% versus 5%) (p=0.01)., Conclusions: These findings suggest that the pandemic has profoundly affected care by acute mental health services.

Background: Responses to anticipateddiscrimination are common among mental health service users and can have adetrimental impact on their recovery. Since 2009, the Time to Change (TTC)anti-stigma program in England has aimed to improve service users' empowerment,reducing public stigma and discrimination. In this paper, we aim to evaluatewhether service users' awareness of TTC is associated with fewer responses toanticipated discrimination., Methods: We used data collected for the evaluation of TTC from samples of mental health service users interviewed by telephone in annual surveys 2009-2014., Results: Five thousand and nine hundredand twenty-three participants completed the survey, mainly suffering from mooddisorders (depression, 28.4%, n = 1,681) and schizophrenia related disorders(15.4%, n = 915).In 23.2% of cases,participants were aware of any aspects of the TTC program, while participationin TTC was reported by 2.6%. Being aware of the TTC program was notsignificantly associated with responses to anticipated discrimination, exceptfor those participating in the TTC campaign in 2013. Stopping oneself fromapplying for work was significantly associated with experienced discriminationin both finding (p &lt; 0.001) and keeping (p &lt; 0.001) a job.Concealing mental health problems was associated with a general experience ofbeing shunned (p &lt; 0.001)., Conclusions: Awareness of a nationalanti-stigma program may not be sufficient to encourage people to seek work/educationor to be open about their illness in situations in which they currentlyanticipate discrimination. There is the need to identify new multi-levelstrategies for challenging anticipated discrimination, even focusing ondifferent target groups.

Attention deficit/hyperactivity disorder (ADHD) often persists into adulthood. Although its persistence and relative high prevalence, ADHD in adults is often underdiagnosed and undertreated in Italy, leading to poor clinical and functional outcomes, and higher costs of illness. The aims of the study were to identify the Italian mental health services for ADHD in adults, describe the diagnostic and treatment procedures they follow, and compare this offer with the recommendations of the German and English guidelines. The centres, that adopt a clinical and assessment protocol for adult ADHD diagnosis (carried out by specifically trained personnel) and prescribe pharmacological treatment for adult ADHD, were selected from the list of accredited services provided by the Appendix B.2 of the ISTISAN 16/37 Reports of the ISS. An ad-hoc survey including open-ended and close-ended questions was sent to each selected centre in February 2020. The overall picture resulting from the data analysis was compared with the recommendations of the German and English guidelines. The present survey shows that only a few centres are specialised in the diagnosis and treatment of ADHD in adults in Italy. Furthermore, there are no national guidelines for adult ADHD in Italy. The collected data also suggest that there is no a unified practice shared by the Centres both for the patient's transition from child and adolescent to adult mental health services and for the diagnostic-therapeutic process. It is therefore crucial to create specific protocols and develop national guidelines to better identify and diagnose ADHD in adults and provide targeted and more efficient multimodal treatments.

Background: Improving openness-including candour when things go wrong, and willingness to learn from mistakes-is increasingly seen as a priority in many healthcare systems. This study explores perceptions of openness in England before and after the publication of the Francis report (2013), which examined failings of openness at one English hospital. We examine whether staff and patients' views on openness, and experiences of giving voice to concerns, have changed since the report's publication for better or worse., Methods: Organisational-level data was collated for all trusts from the NHS National Staff Survey (2007-2017), NHS Acute Inpatient Survey (2004-2016) and NHS Community Mental Health Service User Survey (2007-2017). Survey items related to openness were identified and longitudinal statistical analysis conducted (piecewise growth curve and interrupted latent growth curve analysis) to determine whether there was evidence of a shift in the rate or direction of change following publication of the Francis report., Results: For some variables there was a discernible change in trajectory after the publication of the Francis report. Staff survey variables continued to rise after 2013, with a statistically significant increase in rate for "fairness and effectiveness of incident reporting procedures" (from + 0.02 to + 0.06 per year; p < .001). For the patient surveys, the picture was more mixed: patient views about information provided by accident and emergency staff rose from a 0.3% increase per year before 2013 to 0.8% per year afterwards (p < .01), and inpatients being involved in decision making increased from a 0.4% rise per year before 2013 to 0.8% per year afterwards (p < .01); however, there were not rises in the other questions. Mental health patients reported a decrease after 2013 in being listened to (decreasing at a rate of 1.9% per year, p < .001)., Conclusions: Data suggest that the Francis inquiry may have had a positive impact on staff and acute inpatients' perceptions and experiences of openness in the NHS. However such improvements have not transpired in mental health. How best to create an environment in which patients can discuss their care and raise concerns openly in mental health settings may require further consideration.

Objective: Previous research suggests that up to 90% of individuals who die by suicide may have a mental disorder at the time of death but that levels of treatment may be low. This study aimed to examine undertreatment among patients with mental health conditions who died by suicide and to assess the association between patients' clinical and sociodemographic characteristics and treatment receipt., Methods: The study's sample included 12,909 patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2001 and 2016. All patients had received a diagnosis of bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Records of patients who were not receiving treatment as recommended by national clinical guidelines at the time of death were examined for levels of nonprescription of treatment and nonadherence., Results: Twenty-four percent of the patients did not receive treatment, 11% had not been prescribed treatment, and 13% were nonadherent with treatment. These proportions differed by diagnosis. After adjustment for main primary diagnosis, analyses showed that being under age 40, unemployment, living alone, drug misuse, medication side effects, and comorbid personality disorder were independently associated with a decreased likelihood of receiving treatment., Conclusions: One-quarter of patients with mental health conditions who die by suicide may not be receiving relevant interventions at the time of death. Levels of and reasons for nontreatment vary by diagnosis, but measures to address comorbid diagnoses and implement interventions to improve adherence in specific groups could have an impact.

Objective: In April 2015, the English National Health Service started implementing the first waiting time targets in mental health care. This study aims to investigate the effect of the 14-day waiting time target for early intervention in psychosis (EIP) services after the first six months of its implementation., Study Design: We analyse a cohort of first-episode psychosis patients from the English administrative Mental Health and Learning Disabilities Dataset 2011 to 2015. We compare patients being treated by EIP services (treatment) with those receiving care from standard community mental health services (control). We combine non-parametric matching with a difference-in-difference approach to account for observed and unobserved group differences. We analyse the probability of waiting below target and look at different percentiles of the waiting time distribution., Results: EIP patients had an 11.6-18.4 percentage point higher chance of waiting below target post-policy compared to standard care patients. However, post-policy trends at different percentiles of the waiting time distribution were not different between groups., Conclusions: Mental health providers seem to respond to waiting time targets in a similar way as physical health providers. The increased proportion waiting below target did not, however, result in an overall improvement across the waiting time distribution.

Background: Mental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives' practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health., Objective: To identify midwives' views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines., Design: Nine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data., Findings: Three key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial 'booking' appointment' and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives., Conclusions: This study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Around 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness., Aims: A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation., Method: We used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics., Results: Overall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92-21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01-7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice., Conclusions: Most people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.

Objectives: Autism is difficult to identify in adults due to lack of validated self-report questionnaires. We compared the effectiveness of the autism-spectrum quotient (AQ) and the Ritvo autism-Asperger's diagnostic scale-revised (RAADS-R) questionnaires in adult mental health services in two English counties., Methods: A subsample of adults who completed the AQ and RAADS-R were invited to take part in an autism diagnostic observation schedule (ADOS Module 4) assessment with probability of selection weighted by scores on the questionnaires., Results: There were 364 men and 374 women who consented to take part. Recorded diagnoses were most commonly mood disorders (44%) and mental and behavioural disorders due to alcohol/substance misuse (19%), and 4.8% (95% CI [2.9, 7.5]) were identified with autism (ADOS Module 4 10+). One had a pre-existing diagnosis of autism; five (26%) had borderline personality disorders (all female) and three (17%) had mood disorders. The AQ and RAADS-R had fair test accuracy (area under receiver operating characteristic [ROC] curve 0.77 and 0.79, respectively). AQ sensitivity was 0.79 (95% CI [0.54, 0.94]) and specificity was 0.77 (95% CI [0.65, 0.86]); RAADS-R sensitivity was 0.75 (95% CI [0.48, 0.93]) and specificity was 0.71 (95% CI [0.60, 0.81])., Conclusions: The AQ and RAADS-R can guide decisions to refer adults in mental health services to autism diagnostic services., (© 2020 The Authors. International Journal of Methods in Psychiatric Research Published by John Wiley & Sons Ltd.)

This paper aims to contribute to the prevention of future domestic homicide by analysing 141 domestic homicide reviews (DHRs) in England and Wales. All publicly available DHRs (n = 141) were retrieved from Community Safety Partnership websites in England and Wales in June 2016. Utilising a mixed methods approach, we designed templates to extract quantitative and qualitative data from DHRs. Descriptive statistics were generated by SPSS. 54 DHRs were analysed qualitatively, using N-Vivo for data management. The findings revealed that perpetrators were aged: 16-82 years; with a mean average age of 41 years. Victims' ages ranged from 17 to 91 years old; with a mean average age: 45 years. Perpetrators' mental health was mentioned in 65% of DHRs; 49% of perpetrators had a mental health diagnosis. Healthcare services, in particular, mental health services, were most likely to be involved with perpetrators. 'Movement' was identified as a key contextual feature of the 54 DHRs analysed qualitatively and this was found to interact with risk assessment, language barriers and housing problems. In conclusion, domestic violence and abuse risk assessments need to be informed by the knowledge that domestic abuse occurs across the age span. Mental health settings offer an opportunity for intervention to prevent domestic homicide. Domestic Homicide Reviews can provide valuable material for training practitioners., (© 2019 John Wiley & Sons Ltd.)

Background: Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders., Methods: We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups., Results: Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42-1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50-9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population., Conclusions: People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.

Background: In England, forensic psychiatric hospital services are provided at three security levels: high, medium and low. All are publicly funded and similarly regulated, but medium and low secure services are provided in the private and charitable (PCS) sector as well as the National Health Service (NHS). Originally, medium secure hospital services were conceived as for up to 2 years' inpatient stay, but numbers of longer stay patients have been rising. Little is known about their characteristics or whether they differ between NHS and PCS settings., Aims: To describe and compare characteristics of long-stay patients in NHS and in PCS medium security hospital units., Methods: Data were extracted from clinical records in 14 NHS and 9 PCS hospital units for all patients fulfilling criteria for long stay: having been in high security for more than 10 years or medium security for more than 5 years or in a mix of both for more than 15 years in total., Results: 178 NHS and 107 PCS patients were eligible for inclusion, respectively, 16 and 22% of the total patient populations in these settings. The mean length of stay in a medium or high secure setting was similar: 163 and 164 months. Characteristics of the patients, however, differed between unit type. NHS services admitted more patients from prison and PCS services more from other hospitals. NHS services included a lower proportion of patients with personality disorder or intellectual disability. 'Challenging behaviour' was more prevalent in PCS; a history of absconding was found more often among NHS patients., Conclusions: The two systems of service appear to be used differently. More research is needed to explain why patients apparently without behavioural disturbances remain in specialist secure facilities for such a long time and whether their needs are truly being met in the least restrictive environment possible., (© 2020 John Wiley & Sons Ltd.)

Background: Acute Day Units (ADUs) exist in some English NHS Trusts as an alternative to psychiatric inpatient admission. However, there is a lack of information about the number, configuration, and functioning of such units, and about the extent to which additional units might reduce admissions. This cross-sectional survey and cluster analysis of ADUs aimed to identify, categorise, and describe Acute Day Units (ADUs) in England., Methods: English NHS Mental Health Trusts with ADUs were identified in a mapping exercise, and a questionnaire was distributed to ADU managers. Cluster analysis was used to identify distinct models of service, and descriptive statistics are given to summarise the results of the survey questions., Results: Two types of service were identified by the cluster analysis: NHS (n = 27; and voluntary sector services (n = 18). Under a third of NHS Trusts have access to ADUs. NHS services typically have multi-disciplinary staff teams, operate during office hours, offer a range of interventions (medication, physical checks, psychological interventions, group sessions, peer support), and had a median treatment period of 30 days. Voluntary sector services had mostly non-clinically qualified staff, and typically offered supportive listening on a one-off, drop-in basis. Nearly all services aim to prevent or reduce inpatient admissions. Voluntary sector services had more involvement by service users and carers in management and running of the service than NHS services., Conclusions: The majority of NHS Trusts do not provide ADUs, despite their potential to reduce inpatient admissions. Further research of ADUs is required to establish their effectiveness and acceptability to service users, carers, and staff.

Aims: Mental health stigma and discrimination are significant problems. Common coping orientations include: concealing mental health problems, challenging others and educating others. We describe the use of common stigma coping orientations and explain variations within a sample of English mental health service users., Methods: Cross-sectional survey data were collected as part of the Viewpoint survey of mental health service users' experiences of discrimination (n = 3005). Linear regression analyses were carried out to identify factors associated with the three stigma coping orientations., Results: The most common coping orientation was to conceal mental health problems (73%), which was strongly associated with anticipated discrimination. Only 51% ever challenged others because of discriminating behaviour, this being related to experienced discrimination, but also to higher confidence to tackle stigma., Conclusions: Although stigma coping orientations vary by context, individuals often choose to conceal problems, which is associated with greater anticipated and experienced discrimination and less confidence to challenge stigma. The direction of this association requires further investigation.

Purpose: This study aims to examine whether psychiatric diagnosis is associated with likelihoods of experienced and anticipated workplace discrimination and the concealment of psychiatric diagnoses., Methods: 5924 mental health service users in England were interviewed as part of the Viewpoint survey between 2009 and 2014 using the Discrimination and Stigma Scale. Associations of psychiatric diagnosis with experienced and anticipated work-related discrimination or the concealment of mental illness were examined with the use of logistic regression models., Results: 25.6% of the participants reported experiencing discrimination in at least one work-related domain, contrasting with the 53.7% who anticipated workplace discrimination and the 72.9% who had concealed their mental illness. There was strong evidence that patients with schizophrenia and schizoaffective disorder had a decreased risk of experienced discrimination in keeping a job compared to those with depression, anxiety disorder, bipolar disorder or personality disorder. Furthermore, patients with depression were more likely to report anticipated discrimination in applying for education or training compared to those with schizophrenia and schizoaffective disorder. In addition, patients with depression were more likely to conceal their mental illness compared to those with schizophrenia and schizoaffective disorder and bipolar disorder., Conclusion: This study suggests that psychiatric diagnosis is a predictor of experienced and anticipated workplace discrimination and the concealment of mental illness and that more support is needed for employees with common mental disorders and their employers to enable better workplace outcomes for this group.

Background: Duration of untreated psychosis (DUP) is an important measure of access to care as it predicts prognosis and treatment outcomes. Little is known about potential socioeconomic inequalities in DUP. The aim of this study was to investigate inequalities in DUP associated with socioeconomic deprivation in a national cohort in England., Method: We analysed a cohort of 887 patients with a first-episode in psychosis using the administrative Mental Health Services Dataset in England for 2012/13-2014/15. We used a Generalised Linear Model to account for non-linearity in DUP and looked at inequalities across the whole distribution of DUP using quantile regression., Results: The median DUP was 22 days (mean = 74 days) with considerable variations between and within the 31 hospital providers. We found evidence of significant inequalities regarding the level of socioeconomic deprivation. Patients living in the second, third and fourth deprived neighbourhood quintiles faced a 36, 24 and 31 day longer DUP than patients from the least deprived neighbourhoods. Inequalities were more prevalent in higher quantiles of the DUP distribution. Unemployment prolonged DUP by 40 days. Having been in contact with mental health care services prior to the psychosis start significantly reduced the DUP by up to 53 days., Conclusions: Socioeconomic deprivation is an important factor in explaining inequalities in DUP. Policies to improve equitable access to care should particularly focus on preventing very long delays in treatment and target unemployed patients as well as people that have not been in contact with any mental health professional in the past.

Objectives: The reasons for ethnic differences in women's mental health service use in England remain unclear. The aims of this study were to ascertain: ethnic differences in women's usage of mental health services, if social networks are independently associated with service use, and if the association between women's social networks and service use varies between ethnic groups., Design: Logistic regression modelling of nationally representative data from the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) survey conducted in England. The analytic sample (2260 women, aged 16-74 years) was drawn from the representative subsample of 2340 women in EMPIRIC for whom data on mental health services, and social networks were available., Results: Pakistani and Bangladeshi women were less likely than White women to have used mental health services (Pakistani OR = 0.23, CI = 0.08-0.65, p = .005; Bangladeshi OR = 0.25, CI = 0.07-0.86, p = .027). Frequent contact with relatives reduced mental health service use (OR = 0.45, CI = 0.23-0.89, p = .023). An increase in perceived inadequate support in women's close networks was associated with increased odds of using mental health services (OR = 1.91, CI = 1.11-3.27, p = .019). The influence of social networks on mental health service use did not differ between ethnic groups., Conclusions: The differential treatment of women from Pakistani and Bangladeshi ethnic groups in primary care settings could be a possible reason for the observed differences in mental health service use.

Purpose: Forensic services provide care for mentally disordered offenders. In England this is provided at three levels of security-low, medium and high. Significant number of patients within these settings remain detained for protracted periods of time. This is both very costly and restrictive for individuals. No national studies have been conducted on this subject in England., Methods: We employed a cross-sectional design using anonymised data from medical records departments in English secure forensic units. Data were collected from a large sample of medium secure patients (n = 1572) as well as the total high secure patient population (n = 715) resident on the census date (01-04-2013). We defined long-stay as a stay of more than 10 years in high, 5 years in medium or 15 years in a mix of high and medium secure settings. Long-stay status was assessed against patient demographic and admission information., Results: We identified a significant proportion of long-stayers: 23.5% in high secure and 18.1% in medium secure care. Amongst medium secure units a large variation in long-stay prevalence was observed from 0 to 50%. Results indicated that MHA section, admission source and current ward type were independent factors associated with long-stay status., Conclusion: This study identified a significant proportion of long-stayers in forensic settings in England. Sociodemographic factors identified in studies in individual settings may be less important than previously thought. The large variation in prevalence of long-stayers observed in the medium secure sample warrants further investigation.

Background: Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care., Method: Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812)., Results: In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (β = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (β = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (β = -4.89, 95% CI -13.34 to 3.56, P = 0.26)., Conclusions: This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.

Aims: In the field of stigma research, an area of interest is the coping strategies that mental health service users can use in response to discriminatory experiences. As a part of the evaluation of the Time to Change (TTC) anti-stigma programme, the Viewpoint telephone survey was run annually in order to assess service users' reported levels of discrimination and selected coping strategies. The study aim is to test the extent to which experience of TTC programme is a positive predictor of selected coping strategies., Methods: Telephone interview surveys carried out by peer interviewers were conducted annually. 'Educating others' and 'challenging' coping strategies were assessed alongside anticipated and experienced discrimination., Results: During 2011-2014, 3903 mental health service users were interviewed. Participants more often adopted the 'educating others' strategy (2.31 ± 0.01) than the 'challenging' strategy (2.15 ± 0.02) (p < 0.001). On the other hand, those who participated in campaign activities endorsed 'challenging' more frequently than people who were not aware of TTC (2.78 ± 1.23 v. 2.09 ± 1.08, p < 0.001). According to the multi-variate linear regression model, we found that being actively involved in TTC activities (OR = 0.74, CI: 0.29-1.19; p < 0.05), having a diagnosis of a depressive disorder (OR = 0.20, CI: 0.04-0.36; p < 0.05) or personality disorder (OR = 0.23, CI: 0.04-0.43; p < 0.05) were good predictors of endorsing a 'challenging' strategy even after adjusted for confounding variables., Conclusions: A positive relationship between participating in the TTC programme and using the 'challenging' strategy was found. There is still a need to disentangle the complex association between these two coping strategies and the role of anti-stigma campaigns, promoting further local activities led by service users and carers' as well as all others stakeholders' associations.

Sessional monitoring of patient progress or experience of therapy is an evidence-based intervention recommended by healthcare systems internationally. It is being rolled out across child and adolescent mental health services (CAMHS) in England to inform clinical practice and service evaluation. We explored whether patient demographic and case characteristics were associated with the likelihood of using sessional monitoring. Multilevel regressions were conducted on N = 2609 youths from a routinely collected dataset from 10 CAMHS. Girls (odds ratio, OR 1.26), older youths (OR 1.10), White youths (OR 1.35), and youths presenting with mood (OR 1.46) or anxiety problems (OR 1.59) were more likely to have sessional monitoring. In contrast, youths under state care (OR 0.20) or in need of social service input (OR 0.39) were less likely to have sessional monitoring. Findings of the present research may suggest that sessional monitoring is more likely with common problems such as mood and anxiety problems but less likely with more complex cases, such as those involving youths under state care or those in need of social service input.

Several indicators of population mental health in the UK have deteriorated since the financial crisis, during a period when a number of welfare reforms and austerity measures have been implemented. We do not know which groups have been most affected by these trends or the extent to which recent economic trends or recent policies have contributed to them. We use data from the Quarterly Labour Force Survey to investigate trends in self reported mental health problems by socioeconomic group and employment status in England between 2004 and 2013. We then use panel regression models to investigate the association between local trends in mental health problems and local trends in unemployment and wages to investigate the extent to which these explain increases in mental health problems during this time. We found that the trend in the prevalence of people reporting mental health problems increased significantly more between 2009 and 2013 compared to the previous trends. This increase was greatest amongst people with low levels of education and inequalities widened. The gap in prevalence between low and high educated groups widened by 1.29 percentage points for women (95% CI: 0.50 to 2.08) and 1.36 percentage points for men (95% CI: 0.31 to 2.42) between 2009 and 2013. Trends in unemployment and wages only partly explained these recent increases in mental health problems. The trend in reported mental health problems across England broadly mirrored the pattern of increases in suicides and antidepressant prescribing. Welfare policies and austerity measures implemented since 2010 may have contributed to recent increases in mental health problems and widening inequalities. This has led to rising numbers of people with low levels of education out of work with mental health problems. These trends are likely to increase social exclusion as well as demand for and reliance on social welfare systems., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations., Methods: We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions ("individual;" "natural;" "social;" "supernatural;" "no attribution") were assessed., Results: Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85)., Conclusion: Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

Background: A youth justice diversion scheme designed to enhance health provision for young people with mental health and developmental problems as soon as they enter the youth justice system has been piloted in six areas of England., Aim: As part of a wider evaluation of the first youth justice diversion scheme outside the USA, our aim here was to examine re-offending. We sought to test the hypothesis that a specialised service for young people with mental health difficulties would be associated with reductions in re-offending. In addition, we examined factors associated with the re-offending that occurred., Methods: Two hundred and eight young offenders with access to the diversion scheme and 200 without were compared in four geographical area pairings to allow for socio-demographic contextual differences. Officially recorded re-offending was ascertained for 15-30 months after study entry. We also tested characteristics associated with re-offending among everyone entering the diversion scheme (n = 870)., Results: There was no statistically significant difference in re-offending rates between the diversion and comparison samples, but those with access to diversion had significantly longer periods of desistance from offending than those who did not. In multivariate analysis, the only significant characteristic associated with re-offending was history of previous offending., Conclusions: Prevention of re-offending is only one of the potentially beneficial outcomes of diversion of young people who are vulnerable because of mental health problems, but it is an important one. The advantage of longer survival without prevention of re-offending suggests that future research should explore critical timings for these young people. The equivocal nature of the findings suggests that a randomised controlled trial would be justified., (Copyright © 2014 John Wiley & Sons, Ltd.)

Objective: to investigate (i) the consistency and completeness of mental health assessment documented at hospital booking; (ii) the subsequent management of pregnant women identified as experiencing, or at risk of, mental health problems; and (iii) women's experiences of the mental health referral process., Design: mixed methods cohort study, Setting: large, inner-city hospital in the north of England, Participants: women (n=191) booking at their first formal antenatal appointment; mean gestational age at booking 13 weeks., Methods: women self-completed the routine mental health assessment in the clinical handheld maternity notes, followed by a research pack. Documentation of mental health assessment (including assessment of depression symptoms using the Whooley and Arroll questions, and mental health history), mental health referrals and their management were obtained from women's health records following birth. Longitudinal semi-structured interviews were conducted with a purposive sub-sample of 22 women during and after pregnancy., Findings: documentation of responses to the Whooley and Arroll questions was limited to the handheld notes and symptoms were not routinely monitored using these questions, even for women identified as possible cases of depression. The common focus of referrals was on the women's previous mental health history rather than current depression symptoms, assessed using the Whooley questions. Women referred to a Mental Health Specialist Midwife for further support were triaged based on the written referral and few met eligibility criteria. Although some women initially viewed the referral as offering a 'safety net', analysis of health records and subsequent interviews with women both indicated that communication regarding the management of referrals was inadequate and women tended not to hear back about the outcome of their referral., Key Conclusions and Implications for Practice: mental health assessment was introduced without ensuring that identified needs would be managed consistently. Care pathways and practices need to encompass identification, subsequent referral and management of mental ill-health, and ensure effective communication with patients and between health professionals., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Evaluations of the Improving Access to Psychological Therapies (IAPT) scheme have not yet focused on minority subgroups. This paper aims to evaluate accessibility, waiting times and clinical outcomes of IAPT for older adults., Methods: All referrals from six Primary Care Trusts (PCT) in the East of England were used in this analysis. During each session, the therapist recorded information on anxiety symptoms using the Generalised Anxiety Disorder Questionnaire (GAD-7) and depressive symptoms with the Patient Health Questionnaire (PHQ-9). Waiting times, type of referrals and reliable recovery rates were investigated., Results: Older adults accounted for only 4% of all the IAPT referrals made between September 2008 and July 2010 in the Eastern Region. Waiting times for both IAPT assessment and treatment were slightly lower for older adult. In all centres, reliable recovery rates were higher in older adults compared to younger adults post-treatment, however these differences were not significant, with the exception of a difference in anxiety scores (χ(2)(1) = 18.6, p < 0.001). In multivariate analyses, being an older adult was associated with recovery for depression (OR = 1.30, 95% CI 1.10-1.53), anxiety (OR = 1.42, 95% CI 1.21-1.66), and overall recovery (OR = 1.31, 95% CI 1.10-1.54) after adjustment for gender, PCT region, baseline score, maximum treatment step during treatment, dropping out, and number of sessions., Conclusions: The IAPT services were shown to be beneficial to older patients, however, access to these services in later life has been lower than expected. The service pathway for older populations needs to be better researched in order to eliminate possible obstacles in accessing services., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite the available epidemiological evidence on the prevalence of mental health problems in childhood and adolescence, there is limited knowledge on whether there are differences in the level of need and service utilisation by young ethnic minority groups., Methods: Adolescents of 13-15 years from nine schools in two English cities in which children of Indian ethnicity were over-represented (n=2900), completed rating scales on different types of mental health problems, contacts with services and informal supports., Results: Indian adolescents scored significantly lower on general mental health and depression symptoms. They were also less likely than White adolescents to self-report having mental health problems, even for a similar level of need. Among those with mental health scores within the clinical range, Indian adolescents were less likely to have visited specialist services. Instead, they were more likely to first approach family members, teachers or general practitioners., Conclusions: Rather than a blanket approach being applied to policy and service planning to meet the needs of diverse communities of young people, more specific evidence needs to be gained about patterns of referrals of minority groups and their strategy of accessing supportive adults.

Background: Stigmatizing attitudes can impair the quality of life of people with mental health problems. Psychiatric hospitalization can generate stigma. Are some approaches to care less stigmatizing than others?, Aims: This study was designed to replicate findings from Flanders, Belgium in an English context, investigating how ward size and treatment approach affected service users' expectations and experiences of stigma., Methods: The translated Belgian questionnaire was administered to 70 service users in 15 inpatient adult mental health settings in central England. Adjustments were made to the multivariate analysis in light of the smaller sample size, in order to replicate the original equation as closely as possible., Results: Neither ward size nor individualized care proved significant in the smaller English sample, which was subject to the risk of type II error. Across two models, self-rejection correlated with age (negatively), social rejection and stigma expectations., Conclusions: This analysis shows that attempts to translate evidence about psychiatric inpatient services must take into account differences between the settings, populations and models of care. Expectations as well as outcomes of stigma may be relevant when assessing the impact of psychiatric hospital treatment on individual patients.

Background: The prevalence of mental disorders among prisoners is considerably higher than in the general population. This is an important public health issue as the vast majority of prisoners stay in custody for less than 9 months and, when not in prison, offenders' lifestyles are frequently chaotic, characterized by social exclusion, instability and unemployment. Multi-disciplinary mental health inreach services were introduced to target care towards prisoners with severe mental illness (SMI) in a similar way to that provided by Community Mental Health Teams outside prison. The aim was to establish the proportion of prisoners with SMI who were assessed and managed by prison mental health inreach services. Method A two-phase prevalence survey in six prisons in England measured SMI upon reception into custody. Case-note review established the proportion of those with SMI subsequently assessed and treated by inreach services., Results: Of 3492 prisoners screened, 23% had SMI. Inreach teams assessed only 25% of these unwell prisoners, and accepted just 13% onto their caseloads., Conclusions: Inreach teams identified and managed only a small proportion of prisoners with SMI. Prison-based services need to improve screening procedures and develop effective care pathways to ensure access to appropriate services. Improved identification of mental illness is needed in both the community and the Criminal Justice System to better engage with socially transient individuals who have chaotic lifestyles and complex needs.

Purpose: The purpose of this study is to investigate whether minority ethnic people were less likely to receive treatment for mental health problems than the white population were, controlling for symptom severity., Method: We analysed data from 23,917 participants in the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. Survey response rates were 79, 69 and 57 %, respectively. The revised Clinical Interview Schedule was used to adjust for symptom severity., Results: Black people were less likely to be taking antidepressants than their white counterparts were (Odds ratio 0.4; 95 % confidence interval 0.2-0.9) after controlling for symptom severity. After controlling for symptom severity and socioeconomic status, people from black (0.7; 0.5-0.97) and South Asian (0.5; 0.3-0.8) ethnic groups were less likely to have contacted a GP about their mental health in the last year., Conclusions: Interventions to reduce these inequalities are needed to ensure that NHS health care is delivered fairly according to need to all ethnic groups.

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the world's overall prison population of over 10 million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related., Method: Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan-Meier analysis and Cox regression., Results: Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%-4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients., Conclusion: This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted., Significant Outcomes: This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted., Limitations: Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together., (Copyright © 2012 John Wiley & Sons, Ltd.)

Aim: To investigate the effectiveness of an early intervention in psychosis (EIP) service on engagement and hospital bed usage, post-discharge. A secondary aim was to identify if there was a subgroup of patients with 'poor outcomes'., Method: A naturalistic study comparing engagement and hospital bed day usage of individuals who received treatment from an EIP service (n = 75) with those who presented before the service was established (n = 113)., Results: The EIP service demonstrated better engagement with service users in year 5 (P = 0.001). No significant differences were observed on hospital bed day usage. When 'poor outcome' cases were removed, a trend towards lower bed usage in EIP services emerged (P = 0.139)., Conclusion: EIP services improve engagement with service users. There was not a significant reduction in hospital bed usage. However, advantages could be masked by a relatively small number of individuals with 'poor outcomes'., (© 2012 Wiley Publishing Asia Pty Ltd.)

Background: High-quality evidence on morale in the mental health workforce is lacking., Aims: To describe staff well-being and satisfaction in a multicentre UK National Health Service (NHS) sample and explore associated factors., Method: A questionnaire-based survey (n = 2258) was conducted in 100 wards and 36 community teams in England. Measures included a set of frequently used indicators of staff morale, and measures of perceived job characteristics based on Karasek's demand-control-support model., Results: Staff well-being and job satisfaction were fairly good on most indicators, but emotional exhaustion was high among acute general ward and community mental health team (CMHT) staff and among social workers. Most morale indicators were moderately but significantly intercorrelated. Principal components analysis yielded two components, one appearing to reflect emotional strain, the other positive engagement with work. In multilevel regression analyses factors associated with greater emotional strain included working in a CMHT or psychiatric intensive care unit (PICU), high job demands, low autonomy, limited support from managers and colleagues, age under 45 years and junior grade. Greater positive engagement was associated with high job demands, autonomy and support from managers and colleagues, Black or Asian ethnic group, being a psychiatrist or service manager and shorter length of service., Conclusions: Potential foci for interventions to increase morale include CMHTs, PICUs and general acute wards. The explanatory value of the demand-support-control model was confirmed, but job characteristics did not fully explain differences in morale indicators across service types and professions.

Aims: Prisoners with mental illness on release from prison often face complex challenges with little support, leading to poor clinical and social outcomes. This feasibility study aimed to see whether a Critical Time Intervention (CTI) in the first weeks post-release effectively connects mentally ill prisoners with social, clinical, housing, and welfare services on leaving prison. The study took place in 2007 and involved local prisons in London and Manchester., Methods: A pilot randomised controlled trial in which CTI was compared to Treatment as Usual (TAU)., Results: Sixty prisoners were randomised in the trial, with outcome measures completed on 23. A higher proportion of prisoners in CTI group were in contact with services at follow-up than those receiving TAU. CTI prisoners were significantly more likely to be receiving medication, and be registered with a General Practitioner (GP) than those in the TAU group., Conclusions: Continuity of care for prisoners with severe mental illness can be improved by working with them to identify their needs prior to release, and by assisting them to engage effectively to the necessary agencies in the community.

Background: Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions., Aims: To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services., Method: Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission., Results: After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services., Conclusions: Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.