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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.
How psychiatrists introduce themselves in the first consultation may influence the therapeuticrelationship. There is no evidence about what type of introduction patients prefer.
To assess experimentally patients' preferences for how psychiatrists introduce themselves.
Twelve psychiatrists were filmed, each with three different introductions: stating name, profession and reason for consultation; the same, plus information on what will happen during the consultation; and the same, plus disclosure of a personal difficulty. Six randomly selected videos, of different psychiatrists, two of each type of introduction, were rated by each of 120 psychiatric in- and out-patients on Likert-type scales.
Patients gave the most positive ratings to psychiatrists who introduced themselves with information about what will happen in the consultation rather than ones with briefer introductions or with additional personal disclosure (P = 0.002). Preferences were similar in different subgroups.
Psychiatrists should introduce themselves with information about what they intend to do in theconsultation, but without personal disclosure.
The past 30 years have produced no discoveries leading to major changes in
psychiatric practice. The rules regulating research and a dominant
neurobiological paradigm may both have stifled creativity. Embracing a
social paradigm could generate real progress and, simultaneously, make the
profession more attractive.
Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment.
To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment.
A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission.
A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement.
Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.
There are calls to use patient-reported outcomes (PROs) routinely across
mental health services. However, the use of PROs in patients with
psychosis has been questioned.
To examine the concepts and measures of four widely used PROs: treatment
satisfaction, subjective quality of life, needs for care and the quality
of the therapeutic relationship.
We conducted a literature search of academic databases on concepts,
characteristics and psychometric properties of the four PROs in patients
Although numerous concepts and measures have been published, evidence on
the methodological quality of existing PROs is limited. Measures designed
to assess distinct PROs showed a considerable conceptual, operational and
empirical overlap, and some of them also included specific aspects. The
impact of symptoms and cognitive deficits appears unlikely to be of
The popularity of PROs has not been matched with progress in their
conceptualisation and measurement. Based on current evidence, some
recommendations can be made. Distinct and short measures with clinical
relevance and sufficient psychometric properties should be preferred.
Future research should optimise the validity and measurement precision of
PROs, while reducing assessment burden.