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Background: Improving Access to Psychological Therapies (IAPT) constitutes a key element of England's national mental health strategy. Accessing IAPT usually requires patients to self-refer on the advice of their GP. Little is known about how GPs perceive and communicate IAPT services with patients from low-income communities, nor how the notion of self-referral is understood and responded to by such patients. Aims: This paper examines how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgrounds Method: Findings are drawn from in-depth interviews with low-income patients experiencing mental distress (n = 80); interviews with GPs (n = 10); secondary analysis of video-recorded GP-patient consultations for mental health (n = 26). Results: GPs generally supported self-referral, perceiving it an important initial step towards patient recovery. Most patients however, perceived self-referral as an obstacle to accessing IAPT, and felt their mental health needs were being undermined. The way that IAPT was discussed and the pathway for referral appears to affect uptake of these services. Conclusions: A number of factors deter low-income patients from self-referring for IAPT. Understanding these issues is necessary in enabling the development of more effective referral and support mechanisms within primary care. [ABSTRACT FROM AUTHOR]

Background: Current NICE depression guidelines recommend a period of 'active monitoring' prior to commencing treatment with antidepressants. The content of consultations during active monitoring or supportive care has not been previously prescribed.Methods: As part of a randomised trial of supportive care versus supportive care plus SSRI consultation content was measured through patient recall for the purpose of testing equity in content between trial arms. An exploratory analysis of the consultation content measure is presented together with a measure of consultation satisfaction (MISS) and depression severity (HMRD). A score for 'psychoactive consultation content' (PSAC) was generated to enable comparison between groups.Results: 220 patients were randomised in the study. The majority of participants recalled a discussion of practical problems they faced and many reported some element of problem solving; a significant minority reported discussions about changing the way they thought, addressing relationships or talking to trusted friends or family. Consultation content was unrelated to depression outcome although in multivariate analysis it was strongly related to consultation satisfaction.Limitations: This is a secondary analysis based on patient recall of consultation content.Conclusions: Supportive care is not a passive process as patients report several potentially therapeutic discussions within the consultation and these occur regardless of whether antidepressants are prescribed. It is not known whether these discussions do have any therapeutic value in this context. Consultation content was unrelated to outcome in this study but did predict satisfaction with the consultation. Further work is required to validate the patient report of consultation content and to identify what if any consultation strategies have therapeutic effect. [ABSTRACT FROM AUTHOR]

There has been considerable development of guided self-help clinics within primary care. This uncontrolled before-after cohort study examines efficiency and effectiveness of these clinics when supported by paraprofessional mental health workers having little mental health training and experience. Data were collected by seven Graduate Mental Health Workers (GMHW) located in South-west England. Alongside an analysis of clinic attendance and dropout, efficiency was measured with respect to the number and length of sessions to support patients with the effectiveness of the interventions examined with respect to problem severity. Over a 15-month period, 1162 patients were referred to the GMHW clinics with 658 adopting guided self-help. Patients using guided self-help received an average input per patient, excluding assessment, of four sessions of 40 minutes. Dropout rate was comparable to other primary-care-based mental health clinics supported by experienced mental health professionals with 458 patients completing all support sessions. However, only 233 patients went on to attend the 3 months of follow-up session. Effectiveness of guided self-help clinics supported by paraprofessional mental health workers was comparable to that supported by an experienced mental health nurse. Improvements in problem severity were statistically significant, with 55% and 58% (final support session) and 63% and 62% (3 months of follow-up) of patients experiencing clinically significant and reliable change for anxiety and depression, respectively. However, concerns exist over the efficiency of the GMHW clinic especially with respect to the use of longer support sessions and high dropout rate at the 3 months of follow-up session. The paper concludes by highlighting the effectiveness of guided self-help when supported by paraprofessional mental health workers, but questions the utility of the two-plus-one model of service delivery proposing a collaborative care approach as an alternative. [ABSTRACT FROM AUTHOR]

Background: Guidance on management of depression in primary care has focussed mainly on medication and more recently on talking therapies. Poor adherence to antidepressants is seen as a barrier to better outcomes in depression.Aim: To examine the content of consultations for depression, as perceived by patients, and impact of care on adherence to medication.Methods: A cross-sectional study with a questionnaire completed by 107 patients who had been diagnosed with depression by their GP. The questionnaire measured patients' recall of their GP's management with respect to provision of information, sharing decisions and following 'best' practice; it also inquired about their mental state and adherence to and concerns about medication prescribed.Results: Patients believed that GPs often omitted important components of the consultation. Information was often not reaching patients: 41% did not recall a discussion about side effects and 37% about non-addictive nature of antidepressants; 20% about how long medication would take to work, and 25% about benefits of continuing medication after improvement. 20% reported not being involved in decision making. Only one third recalled being asked about self-harm. 41% expressed concern about side effects of antidepressants and 38% wished to cope alone, but reported adherence was relatively high with 64% taking medication as instructed.Conclusions: GPs need to communicate better about medication, perhaps providing more written information about depression and anti-depressants, and ensuring explanations are full and understood. Adherence is affected by key processes in the consultation as well as patient beliefs and background. [ABSTRACT FROM AUTHOR]

Introduction: International policy is encouraging a re-design of health and social care services, including the use of social prescribing. Torbay and South Devon NHS Foundation Trust, an Integrated Care Organisation in the UK, commissioned a voluntary sector ‘Wellbeing Coordination’ service as a key element of the wider care model. This case study seeks to understand how primary, acute, social, community and voluntary services are working together in a locality hub and the impact of wellbeing coordinators on service users’ well-being, use and cost of health and social care services Methods: A before-and-after study, supplemented with qualitative case studies, practitioner interviews/surveys, observations of multidisciplinary team (MDT) meetings and service user/caregiver interactions. Applying an action-based participatory approach, findings were co-produced with stakeholders and members of the public by embedded researchers-in-residence. Quantitative service user data were collected on health and social well-being outcomes and frailty on referral and 12 weeks. Comprehensive activity and cost data were collected at 12 months pre- and post-referral. Results: Health outcomes and service activity data were collected on 49 participants receiving the wellbeing coordination programme. All person-reported outcomes showed statistically significant increases in mean change scores (Warwick-Edinburgh Mental Well-being Scale, Well-being Star™, Patient Activation Measure, Rockwood Clinical Frailty Scale, Living well goals met). Qualitative case studies and observations highlighted key mechanisms of the intervention and the hub working. The impact on health and social care use and cost was more nuanced, with mean activity and cost increasing overall. Referrals from the Enhanced Intermediate Care MDTs (20/49) showed higher levels of use and cost. At locality hub level, the practitioner survey, observations and interview findings show an increase in vertical and horizontal organisational integration and high levels of staff-reported person-centeredness while embodying a strengths-based approach. Discussion: The study shows a positive impact on outcomes and mixed patterns regarding activity and cost. The findings indicate potential for more ‘down-stream’ and preventative work. The close links with the wider voluntary sector add to the hub offer in holding more complexity, providing access and continuity of care, and delivering holistic and personalised care in the right place and at the right time. Conclusion: Key elements of how the hub works indicate the importance of leadership, co-ordination, communication, colocation, and contracting that allows the nourishing of trusting relationships and crossing of organisational and professional boundaries. Lessons learned: Challenges included pooling resources, record sharing, information governance and engaging all stakeholders in a shared vision for a strengths-based, person-centred culture. Ownership and bottom up dynamics and formal and informal relationships between practitioners at all levels, including the community they work with, were key features for overcoming these. Limitations: Case studies and participatory research approaches may be considered lesser to experimental study designs. However, context is crucial to integrated care and extrapolating generalizable findings. Co-production and triangulating varying data sources helps studying and implementing complex system wide transformation. Suggestions for future research: The Researcher-in-Residence model could be rolled out across systems to facilitate learning, and to increase robustness of insights.

Background: Primary care trainees are traditionally taught to use a consultation model which focuses on eliciting the patients’ main reason for consulting “today”. As the number of patients with multi-morbidity increases, this approach is often inappropriate or unhelpful. Patients can be left without an understanding of their interacting health issues. The SHERPA model provides a biopsychosocial framework for consulting patients with multi-morbidity. We aimed to examine the responses to this model when integrated into a training programme for newly registered GPs. Methods: Sixteen participants provide qualitative data on their experience and followup use of SHERPA. Four hours of teaching were observed. Twenty-four feedback templates on training (n=18) and SHERPA application (n=6) were collected. Individual semi-structured one-to-one interviews were conducted with trainees (n=5) and trainers (n=3). Data were transcribed and, using the Framework approach, systematically analysed focussing on the trainees’ reaction to the teaching sessions and their ability to use the SHERPA consultation model. Results: Participants engaged well with the teaching sessions, enjoying the scenarios and bringing observations from their own experience. Five participants went on to apply SHERPA successfully with their patients. Barriers to using this approach were: not seeing appropriate patients with multi-morbidities (due to current placement or patient type); time; lack of confidence and familiarity; concern about missing important immediate clinical issues; and viewing the approach as “in addition” rather than key to shared decisionmaking. Conclusion:TheSHERPA model was viewed as a helpful addition by traineeGPs, although practical issues, fears and not seeing it as their priority for their case-mix, limited their application of it. Regular support from trainers, where trainees reflect on their experience of using SHERPA, could increase their confidence and familiarity with this method. These findings suggest that SHERPA may be relevant to other specialities such as geriatric medicine, where multi-morbidity is common. [ABSTRACT FROM AUTHOR]

Abstract Background Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care. This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? An explanatory research question asks is an increase in mindfulness skills the key mechanism of change? Methods/Design The design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users' views and experiences. Discussion If the results of our exploratory trial are extended to this definitive trial, MBCT will be established as an alternative approach to maintenance anti-depressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. Trial registration number ISRCTN26666654

Abstract Background Complex interventions have components which can vary in different contexts. Using the Realistic Evaluation framework, this study investigates how a complex health services intervention led to developments in shared care for people with long-term mental illness. Methods A retrospective qualitative interview study was carried out alongside a randomised controlled trial. The multi-faceted intervention supported by facilitators aimed to develop systems for shared care. The study was set in London. Participants included 46 practitioners and managers from 12 participating primary health care teams and their associated community mental health teams. Interviews focussed on how and why out comes were achieved, and were analysed using a framework incorporating context and intervening mechanisms. Results Thirty-one interviews were completed to create 12 case studies. The enquiry highlighted the importance of the catalysing, doing and reviewing functions of the facilitation process. Other facets of the intervention were less dominant. The intervention catalysed the allocation of link workers and liaison arrangements in nearly all practices. Case discussions between link workers and GPs improved individual care as well as helping link workers become part of the primary care team; but sustained integration into the team depended both on flexibility and experience of the link worker, and upon selection of relevant patients for the case discussions. The doing function of facilitators included advice and, at times, manpower, to help introduce successful systems for reviewing care, however time spent developing IT systems was rarely productive. The reviewing function of the intervention was weak and sometimes failed to solve problems in the development of liaison or recall. Conclusion Case discussions and improved liaison at times of crisis, rather than for proactive recall, were the key functions of shared care contributing to the success of Mental Health Link. This multifaceted intervention had most impact through catalysing and doing, whereas the reviewing function of the facilitation was weak, and other components were seen as less important. Realistic Evaluation provided a useful theoretical framework for this process evaluation, by allowing a specific focus on context. Although complex interventions might appear 'out of control', due to their varied manifestation in different situations, context sensitive process evaluations can help identify the intervention's key functions.

An understanding of patients' perspectives is crucial to improving engagement with health care services. For older people who may not wish to bother medical professionals with problems of living such as depression, such exploration becomes critical. General practitioners (GPs), nurses and counsellors working in 18 South London primary care teams were interviewed about their perceptions of depression in older people. All three professional groups shared a predominantly psychosocial model of the causes of depression. While presentation of somatic symptoms was seen as common in all age groups, identification of depression in older patients was complicated by co-existent physical illnesses. GPs reported that older patients rarely mentioned psychological difficulties, but practice nurses felt that older people were less inhibited in talking to them about 'non-medical' problems. Many older people were perceived to regard symptoms of depression as a normal consequence of ageing and not to think it appropriate to mention non-physical problems in a medical consultation. Men were thought to be particularly reluctant to disclose emotional distress and were more vulnerable to severe depression and suicide. Some GPs had mixed feelings about offering medication to address what they believed to be the consequences of loneliness and social isolation. Participants thought that many older people regard depression as a 'sign of weakness' and the perceived stigma of mental illness was widely recognised as a barrier to seeking help. Cultural variations in illness beliefs, especially the attribution of symptoms, were thought to profoundly influence the help-seeking behaviour of elders from minority ethnic groups. Families were identified as the main source of both support and distress; and as such their influence could be crucial to the identification and treatment of depression in older people. [ABSTRACT FROM AUTHOR]

Background: The introduction of remote and digital forms of working in UK general practice has driven the development of new routines and working styles., Aim: To explore and theorise how new forms of work have affected general practice staff., Design and Setting: Multi-sited, qualitative case study in UK general practice., Method: Using longitudinal ethnography by researchers in residence, we followed 12 practices for 28 months (September 2021 to December 2023). This core dataset was supplemented by workshops and stakeholder interviews. Data analysis applied theories from the sociology of work, organisation studies, and internet studies., Results: Staff made significant efforts to adapt to and embed digital services into their work. When technologies work well they can offer improved convenience, efficiency, more comprehensive patient care, and workplace fulfilment for staff. However, for many clinical and administrative staff, compromises and frictions embedded in digitalised workplace routines and processes could also lead to job dissatisfaction, worsened wellbeing, and misalignments with professional values and identities. We found that this workplace suffering caused relational strain between team members and had an impact on team cohesiveness and coordination., Conclusion: The digitalisation of working routines in UK general practice poses a unique challenge to the workforce, risking technostress, workplace suffering, and increased relational strain within and between teams. To embed the benefits of digitalisation, we must first improve practice teams' readiness for change, which includes strengthening practices' relational structures that provide support during periods of adaptation. Practices must be empowered to determine a locally appropriate configuration of digital tools and given the resources and time to adapt working routines., (© The Authors.)

Background: Patients presenting to emergency departments (EDs) following an episode of self-harm are at risk of future suicide. There are few evidence-based interventions for self-harm in the ED context in England. This study sought to assess the feasibility of a trial of a newly developed brief psychological intervention, the Assured approach. This approach consisted of an enhanced psychosocial assessment, collaborative safety planning and three rapid solution-focussed follow-up sessions. Phase 1 was a feasibility study, and phase 2 was an internal pilot trial of a cluster randomised controlled trial to assess whether progression to a full-scale trial was warranted., Methods: In phase 1, patients were recruited and allocated to a study arm, the Assured arm or treatment as usual, depending on the allocation of their assessing practitioner, in four EDs in England. They were invited to research assessments after consent and at 6 months. Phase 2 was the internal pilot of a cluster randomised controlled trial conducted in six EDs in England. Practitioners were randomised to deliver the Assured approach or treatment as usual. Patients were recruited and allocated to a study arm depending on the allocation of their assessing practitioner. They were invited to complete research assessments after consent and at 3, 9 and 18 months., Results: Sixty-one patients were recruited into the Assured (n = 46) and treatment as usual (n = 15) arms in phase 1. Findings showed we could recruit and follow up patients over a 6-month period. The research procedures were acceptable to patients and practitioners, and the intervention was delivered with acceptable fidelity to the intervention manual. Forty-seven patients were recruited into the phase 2 internal pilot trial, falling substantially short of our target of 491 in the stop-go criteria, indicating that the trial was not feasible in its current design., Conclusion: The feasibility study indicated that both the intervention and research processes were acceptable. However, the internal pilot trial revealed substantial challenges in recruiting patients and delivering the intervention in the ED context. Adaptations to the trial design and intervention are proposed to enable the Assured approach to be tested in a future trial, to improve care for this underserved population., Trial Registration: ISRCTN16003313, 04/02/2020; ISRCTN13472559, 18/11/2021., Competing Interests: Declarations. Ethics approval and consent to participate: All practitioner and patient participants provided fully informed written consent to take part in this study. Consent for publication: All practitioner and patient participants have consented to publication. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)