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Over the past few years the term ‘service users’ has been increasingly used to describe patients in mental healthcare. This paper argues that the term ‘service user’ in this context should be avoided and outlines four reasons: the term is discriminating, cynical, patronising and detrimental. Of course, none of these effects is intentional, but that does not change them. The term ‘patient’, however, describes appropriately a temporary role in healthcare, provides parity of esteem with patients in physical healthcare and reflects the reasons why large parts of society are willing to fund healthcare, in solidarity with those who are sick.
There appears to be no research to date investigating patients’ preferences for sociocultural characteristics or behavioural qualities of psychiatrists. We aimed to assess which are most important to patients. Patients (132) in community mental health teams across two sites (East Cornwall, East London) completed a questionnaire ranking the importance of different sociocultural characteristics and behaviours of psychiatrists.
Patients cared more about age and gender than other characteristics. Four preferences (from a choice of ten) regarding behavioural qualities were clearly identified as important: explaining things clearly, dedication to personal treatment, being friendly and polite, and being up to date with medical knowledge.
Patients are fairly unconcerned about the age, gender, religion and social background of psychiatrists. Characteristics they care about most include communication skills, competence, dedication to personal treatment and friendliness. Explaining things clearly is particularly important. This indicates specific areas of improvement for training and further research.
A hospital built environment can affect patients’ treatment satisfaction, which is, in turn, associated with crucial clinical outcomes. However, little research has explored which elements are specifically important for psychiatric in-patients. This study aims to identify which elements of the hospital environment are associated with higher patient satisfaction with psychiatric in-patient care.
The study was conducted in Italy and the United Kingdom. Data was collected through hospital visits and patient interviews. All hospitals were assessed for general characteristics, aspects specific to psychiatry (patient safety, mixed/single-sex wards, smoking on/off wards), and quality of hospital environment. Patients’ treatment satisfaction was assessed using the Client Assessment of Treatment Scale (CAT). Multi-level modelling was used to explore the role of environment in predicting the CAT scores adjusted for age, gender, education, diagnosis, and formal status.
The study included 18 psychiatric hospitals (7 in Italy and 11 in the United Kingdom) and 2130 patients. Healthcare systems in these countries share key characteristics (e.g. National Health Service, care organised on a geographical basis) and differ in policy regulation and governance. Two elements were associated with higher patient treatment satisfaction: being hospitalised on a mixed-sex ward (p = 0.003) and the availability of rooms to meet family off wards (p = 0.020).
As hospitals are among the most expensive facilities to build, their design should be guided by research evidence. Two design features can potentially improve patient satisfaction: family rooms off wards and mixed-sex wards. This evidence should be considered when designing or renovating psychiatric facilities.
The value of carer involvement has been extensively researched and promoted. However, the field lacks exploration of conceptual issues, which might help to explain why there are widespread difficulties in putting policy into practice in this area, as implementation rates remain low internationally.
This qualitative study explored patients’, carers’ and clinicians’ perspectives on the role of carers in mental healthcare, particularly with regards to in-patient settings.
Sixteen focus groups were conducted with patients, carers and clinicians who have current or previous experience of in-patient settings. A thematic analysis was conducted on the transcripts, exploring two key domains: (a) what a ‘carer’ is, and (b) how the ‘carer’ role is described within the context of the hospital environment.
Participants diverged in their opinions of what the ‘carer’ role entails, and the perceived helpfulness of it. Issues unique to the in-patient setting were identified, such as the role of the hospital environment in enabling or being a barrier to carer involvement. These differing perspectives and contextual factors had an impact on the position of carers in the hospital setting, as they could be viewed as helpful, a hindrance or as passive visitors, depending on the perspectives of clinicians.
More clarity and agreement is needed between patients, carers and clinicians in terms of how the ‘carer’ role is defined. This has the potential to improve carers’ experience of involvement in hospital settings.
Around 100 000 people live in mental health supported accommodation in England, at considerable cost to the public purse, but there is little evidence to guide investment in the most effective models. We consider the various barriers to research in this field and offer suggestions on how to address them.
The review aims to identify the extent and nature of research on mental disorders and their care in immigrant populations in three major European countries with high levels of immigration, i.e. Germany, Italy, United Kingdom (UK).
Peer-reviewed publications on the subject from the three countries between 1996 and 2004 were analyzed. The research questions addressed, the methods used, and the results obtained were assessed.
Thirteen papers reporting empirical studies were found from Germany, four from Italy and 95 from the UK. Studies addressed a range of research questions and most frequently assessed rates of service utilization in different immigrant groups. The most consistent finding is a higher rate of hospital admissions for Afro-Caribbean patients in the UK. Many studies had serious methodological shortcomings with low sample sizes and unspecified inclusion criteria.
Despite large scale immigration in each of the three studied countries, the numbers of relevant research publications vary greatly with a relatively high level of empirical research in the UK. Possible reasons for this are a generally stronger culture of mental health service research and a higher number of researchers who are themselves from immigrant backgrounds in the UK.
Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.
Previous studies in individual countries have identified inconsistent predictors of length of stay (LoS) in psychiatric inpatient units. This may reflect methodological inconsistencies across studies or true differences of predictors. In this study we assessed predictors of LoS in five European countries and explored whether their effect varies across countries.
Prospective cohort study. All patients admitted over 14 months to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and United Kingdom were screened. Putative predictors were collected from medical records and in face-to-face interviews and tested for their association with LoS.
Average LoS varied from 17.9 days in Italy to 55.1 days in Belgium. In the overall sample being homeless, receiving benefits, social isolation, diagnosis of psychosis, greater symptom severity, substance use, history of previous admission and being involuntarily admitted predicted longer LoS. Several predictors showed significant interaction effects with countries in predicting LoS. One variable, homelessness, predicted a different LoS even in opposite directions, whilst for other predictors the direction of the association was the same, but the strength of the association with LoS varied across countries.
The same patient characteristics have a different impact on LoS in different contexts. Thus, although some predictor variables related to clinical severity and social dysfunction appear of generalisable relevance, national studies on LoS are required to understand the complex influence of different patient characteristics on clinical practice in the given contexts.
Psychiatric facilities are often criticised of being poorly designed which may contribute to violent incidents and patients’ complaints of feeling bored and lacking meaningful interactions with peers and staff. There is a lack of understanding how to design environments for staff, patients and visitors to engage in positive social interactions (e.g. conversation, sharing, peer support). We conducted a systematic literature review on which architectural typologies and design solutions facilitate helpful social interactions between users of psychiatric facilities. Several interventions were identified such as choosing a community location; building smaller (up to 20 beds) homelike and well integrated facilities with single/double bedrooms and wide range of communal areas; provision of open nursing stations; ensuring good balance between private and shared spaces for patients and staff; and specific interior design interventions such as arranging furniture in small, flexible groupings, introduction of plants on wards, and installing private conversation booths. These interventions range from simple and non-costly to very complex ones. The evidence should inform the design of new hospitals and the retrofitting of existing ones.
In this article we re-examine the conclusions of our article on advance statements in adult mental healthcare that was published in 2010 in the light of new literature published in the intervening decade. We explore the results of studies on the implementation and effectiveness of advance statements in adult mental health services, and then summarise recommendations for legislative changes from the Independent Review of the Mental Health Act 1983 that are relevant for England and Wales.
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.
A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation.
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.
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.
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.
Befriending by volunteers has the potential to reduce the frequent social isolation of patients with schizophrenia and thus improve health outcomes. However, trial-based evidence for its effectiveness is limited.
To conduct a randomised controlled trial of befriending for patients with schizophrenia or related disorders.
Patients were randomised to a befriending programme for 1 year or to receive information about social activities only (trial registration: ISRCTN14021839). Outcomes were assessed masked to allocation at the end of the programme; at 12 months and at a 6-month follow-up. The primary outcome was daily time spent in activities (using the Time Use Survey (TUS)) with intention-to-treat analysis.
A total of 124 patients were randomised (63 intervention, 61 active control) and 92 (74%) were followed up at 1 year. In the intervention group, 49 (78%) met a volunteer at least once and 31 (49%) had more than 12 meetings. At 1 year, mean TUS scores were more than three times higher in both groups with no significant difference between them (adjusted difference 8.9, 95% CI −40.7 to 58.5, P = 0.72). There were no significant differences in quality of life, symptoms or self-esteem. However, patients in the intervention group had significantly more social contacts than those in the control group at the end of the 12-month period. This difference held true at the follow-up 6 months later.
Although no difference was found on the primary outcome, the findings suggest that befriending may have a lasting effect on increasing social contacts. It may be used more widely to reduce the social isolation of patients with schizophrenia.
Patient satisfaction is a key indicator of inpatient care quality and is associated with clinical outcomes following admission. Different patient characteristics have been inconsistently linked with satisfaction. This study aims to overcome previous limitations by assessing which patient characteristics are associated with satisfaction within a large study of psychiatric inpatients conducted across five European countries.
All patients with a diagnosis of psychotic (F2), affective (F3) or anxiety/somataform (F4) disorder admitted to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and the UK were included. Data were collected from medical records and face-to-face interviews, with patients approached within 2 days of admission. Satisfaction with inpatient care was measured on the Client Assessment of Treatment Scale.
Higher satisfaction scores were associated with being older, employed, living with others, having a close friend, less severe illness and a first admission. In contrast, higher education levels, comorbid personality disorder and involuntary admission were associated with lower levels of satisfaction. Although the same patient characteristics predicted satisfaction within the five countries, there were significant differences in overall satisfaction scores across countries. Compared to other countries, patients in the UK were significantly less satisfied with their inpatient care.
Having a better understanding of patient satisfaction may enable services to improve the quality of care provided as well as clinical outcomes for all patients. Across countries, the same patient characteristics predict satisfaction, suggesting that similar analytical frameworks can and should be used when assessing satisfaction both nationally and internationally.
In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country’s health system. Since personal continuity would be more suitable for patients with complex psychosocial needs, the aim of this study was to identify predictors of patients’ exposure to care approaches in different European countries.
Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge, patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients’ discharge were assessed in both groups of countries.
Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population.
Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless, organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.
Observational research has found that involuntary treatment provides limited benefits in terms of long-term clinical outcomes. Our aim was to review literature on existing interventions in order to identify helpful approaches to improve outcomes of involuntary treatment.
This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement guidelines. Seven databases (AMED, PsycINFO, Embase Classic, Embase 1974–2017, CINAHL, MEDLINE, and BNI) were searched and the results were analysed in a narrative synthesis.
Nineteen papers describing fourteen different interventions were included. Using narrative synthesis the interventions were summarised into three categories: a) structured patient-centred care planning; b) specialist therapeutic interventions; c) systemic changes to hospital practice. The methodologies used and outcomes assessed were heterogeneous. Most studies were of low quality, although five interventions were tested in randomised controlled trials (RCTs). Preliminary evidence supports structured patient-centred care planning interventions have an effect on long-term outcomes (such as readmission), and that specialist therapeutic interventions and systemic changes to hospital practice have an effect on reducing the use of coercive measures on wards.
This review shows that it is possible to conduct rigorous intervention-testing studies in involuntary patients, including RCTs. Yet, the overall evidence is limited. Structured patient-centred care planning interventions show promise for the improvement of long-term outcomes and should be further evaluated.
Last year, there were more than 63 622 involuntary admissions to psychiatric hospitals in England. One of the core principles stipulated in the code of practice for care under the Mental Health Act is involving involuntary patients in care decisions.
Identifying barriers and facilitators to shared decision-making with involuntary patients.
Focus groups and individual interviews with patients and clinicians who have experience with involuntary hospital treatment were carried out. Data were subjected to thematic analysis.
Twenty-two patients and 16 clinicians participated. Barriers identified included challenges in communication, and noisy and busy wards making one-to-one meetings difficult. Patient involvement was identified as easier if initiated early after admission and if the whole clinical team was on board. Carers' presence helped decision-making through providing additional information and comfort.
The barriers and facilitators identified can inform changes in the practice of involuntary care to increase patient involvement.
Psychosis seminars enable service users, their carers and mental health professionals to meet outside of a formal care setting, increase understanding of mental illness and help establish a dialogue.
To explore feasibility of psychosis seminars in the UK and the experiences of participants.
Seven meetings attended by 25 people were held over a 3-month period. An open-ended questionnaire was returned by ten participants. Responses were subjected to content analysis.
Benefits experienced were having an open forum for talking freely about mental health issues in a neutral space, learning from others about psychosis and hearing different views. Suggested adjustments were clarifying expectations of participants at the beginning, strengthening facilitation and increasing attendance.
Psychosis seminars may help to establish a dialogue among users, carers and professionals and seem feasible in the UK, although adjustment to delivery can help their implementation.
A better therapeutic relationship predicts better outcomes. However,
there is no trial-based evidence on how to improve therapeutic
relationships in psychosis.
To test the effectiveness of communication training for psychiatrists on
improving shared understanding and the therapeutic relationship (trial
In a cluster randomised controlled trial in the UK, 21 psychiatrists were
randomised. Ninety-seven (51% of those approached) out-patients with
schizophrenia/schizoaffective disorder were recruited, and 64 (66% of the
sample recruited at baseline) were followed up after 5 months. The
intervention group received four group and one individualised session.
The primary outcome, rated blind, was psychiatrist effort in establishing
shared understanding (self-repair). Secondary outcome was the therapeutic
Psychiatrists receiving the intervention used 44% more self-repair than
the control group (adjusted difference in means 6.4, 95% CI 1.46–11.33,
P<0.011, a large effect) adjusting for baseline
self-repair. Psychiatrists rated the therapeutic relationship more
positively (adjusted difference in means 0.20, 95% CI 0.03–0.37,
P = 0.022, a medium effect), as did patients
(adjusted difference in means 0.21, 95% CI 0.01–0.41, P
= 0.043, a medium effect).
Shared understanding can be successfully targeted in training and
improves relationships in treating psychosis.
Key elements of a rehabilitation service
Helen Killaspy, Professor of Rehabilitation Psychiatry, Mental Health Sciences Unit, University College London,
Stefan Priebe, Professor of Social and Community Psychiatry, Newham Centre for Mental Health, London,
Geoff Shepherd, Professor of Psychology, Senior Policy Advisor, Centre for Mental Health, London
This chapter describes the history, development and evidence for supported accommodation for people with mental health problems. Clearly, people with mental health problems who do not reside in supported accommodation also need somewhere to live and support to remain as well as possible and maintain their home successfully: in the UK most live alone, although many do live with family. People living in supported accommodation will require the interventions described in Part 2 of this book (‘Treatment approaches’), delivered by the community-based services described in Chapter 18, ‘Community-based rehabilitation and recovery’; these are not reiterated here.
Specialist supported accommodation for people with mental health problems includes nursing and residential care homes, group homes, hostels, blocks of individual or shared tenancies with staff on site, and independent tenancies with ‘floating’ or outreach support from staff. In 2006 it was estimated that around 12 500 people with mental health problems in England were in a nursing or residential care home (National Statistics, 2006), although a recent ‘freedom of information’ enquiry to the organisations commissioning these services – local authorities and National Health Service (NHS) primary care trusts – puts the figure much higher, at around 30 000 (Killaspy & Meier, 2010). This discrepancy could be due to changes in the registration processes for these kinds of facilities, which have led to an increase in the number of homes formally registered, rather than an increase in the actual number of people residing in them, although there has also been greater use of nursing and residential care for people with longer-term mental health problems in the UK in recent years owing to disinvestment in local rehabilitation services (on the ‘virtual asylum’, see Chapter 17, ‘Rehabilitation in hospital settings’). In 2006, around 160 000 people in England were receiving floating outreach services, of whom around 15% (24 000) were classified as receiving a specialist mental health floating outreach service (Department of Communities and Local Government, 2006).
Like other medical specialties, psychiatry has traditionally sought to
develop treatments targeted at ameliorating a deficit of the patient.
However, there are different therapeutic models that focus on utilising
patients' personal and social resources instead of ameliorating presumed
deficits. A synopsis of such models might help to guide further research
and improve therapeutic interventions.
To conduct a conceptual review of resource-oriented therapeutic models in
psychiatry, in order to identify their shared characteristics.
The literature was searched to identify a range of resource-oriented
therapeutic models, particularly for patients with severe mental illness.
Key texts for each model were analysed using a narrative approach to
synthesise the concepts and their characteristics.
Ten models were included: befriending, client-centred therapy, creative
music therapy, open dialogue, peer support workers, positive
psychotherapy, self-help groups, solution-focused therapy, systemic
family therapy and therapeutic communities. Six types of resources were
utilised: social relationships, patients' decision-making ability,
experiential knowledge, patients' individual strengths, recreational
activities and self-actualising tendencies. Social relationships are a
key resource in all the models, including relationships with
professionals, peers, friends and family. Two relationship dimensions –
reciprocity and expertise – differed across the models.
The review suggests that a range of different therapeutic models in
psychiatry address resources rather than deficits. In various ways, they
all utilise social relationships to induce therapeutic change. A better
understanding of how social relationships affect mental health may inform
the development and application of resource-oriented approaches.
Dialectical behaviour therapy (DBT) is associated with particularly high drop-out rates in the National Health Service (NHS). This paper seeks to investigate the characteristics of patients with borderline personality disorder dropping out from DBT and the role of care coordination in this phenomenon. Data for the 102 patients receiving DBT in east London, 58% of whom had dropped out of treatment prematurely, were analysed.
In a multivariable analysis, a history of care coordination was the only variable significantly correlated with drop out: 88% of patients with a history of care coordination dropped out prematurely compared with 52% of patients without such history.
The experience of comprehensive care within the care programme approach, particularly care coordination at the start of DBT, affects the retention of patients in DBT. Further qualitative research is required to understand how care coordination and DBT drop out are related, which could lead to changes in how the therapy is delivered in the UK and influence decisions regarding the use of care coordination with patients with borderline personality disorder.