Sonia Johnson

The REACT study: randomised evaluation of assertive community treatment in north London

Abstract Objective To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses. Design Non-blind randomised controlled trial. Setting Two inner London boroughs. Participants 251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services. Interventions Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants). Main outcome measures Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services. Results No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval −16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4). Conclusions Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

The views and experiences of severely mentally ill mothers--a qualitative study.

Abstract.Background:The majority of women with severe mental illness are mothers. Little is known about their experiences and the extent to which their needs are met.Methods:Semi-structured interviews were carried out with 22 women with schizophrenia, bipolar affective disorder or severe depression with psychotic symptoms in Inner London. Participants’ experiences, views about services and needs for support in parenting were discussed. Interviews were transcribed verbatim and qualitative thematic analysis carried out.Results:Most participants who looked after their children described motherhood as rewarding and central to their lives. However, they described the demands associated with parenting and at the same time coping with severe mental illness as considerable, and some feared that their children would be adversely affected by their illnesses. Parenting responsibilities created practical impediments to engaging with mental health services. Fear of losing custody or access to children dominated interactions with mental health and social services, making most participants reluctant to disclose difficulties in parenting to professionals. A widespread assumption that mentally ill women are inherently poor parents, regardless of the facts of individual cases, was described, and stigma was seen as affecting children as well as mothers. Services were perceived as offering little continuing support in relation to parenting, intervening only in crises.Conclusion:Little attention has so far been paid in research and service development to the fact that the majority of mentally ill women are mothers. Strategies for assessing and meeting the resulting unmet needs should be developed and evaluated.

A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness

BackgroundLittle is known about whether peer support improves outcomes for people with severe mental illness.MethodA systematic review and meta-analysis was conducted. Cochrane CENTRAL Register, Medline, Embase, PsycINFO, and CINAHL were searched to July 2013 without restriction by publication status. Randomised trials of non-residential peer support interventions were included. Trial interventions were categorised and analysed separately as: mutual peer support, peer support services, or peer delivered mental health services. Meta-analyses were performed where possible, and studies were assessed for bias and the quality of evidence described.ResultsEighteen trials including 5597 participants were included. These comprised four trials of mutual support programmes, eleven trials of peer support services, and three trials of peer-delivered services. There was substantial variation between trials in participants’ characteristics and programme content. Outcomes were incompletely reported; there was high risk of bias. From small numbers of studies in the analyses it was possible to conduct, there was little or no evidence that peer support was associated with positive effects on hospitalisation, overall symptoms or satisfaction with services. There was some evidence that peer support was associated with positive effects on measures of hope, recovery and empowerment at and beyond the end of the intervention, although this was not consistent within or across different types of peer support.ConclusionsDespite the promotion and uptake of peer support internationally, there is little evidence from current trials about the effects of peer support for people with severe mental illness. Although there are few positive findings, this review has important implications for policy and practice: current evidence does not support recommendations or mandatory requirements from policy makers for mental health services to provide peer support programmes. Further peer support programmes should be implemented within the context of high quality research projects wherever possible. Deficiencies in the conduct and reporting of existing trials exemplify difficulties in the evaluation of complex interventions.

Mental health, burnout and job satisfaction in a longitudinal study of mental health staff

Background: This study examines whether the adoption of a more community based model in an inner city psychiatry service is accompanied by increasing “burnout”, deteriorating mental health and decreasing job satisfaction amongst staff. Method: Questionnaires were sent annually for 3 consecutive years to all mental health staff working in three adult mental health sectors in inner London. Main outcome measures were the 12-item General Health Questionnaire, Maslach Burnout Inventory and a general job satisfaction measure. Results: There was no significant change over time in the outcome measures, once confounding by job and demographic variables was examined. Being based in the community was associated with higher GHQ-12 scores (P = 0.02) when compared to in-patient staff over the 3 years. Conclusions: These results suggested that working in the community may be more stressful than working in in-patient services. However, there was no evidence to suggest that levels of stress are increasing over time, either in community-based or hospital-based staff.

Initiatives to shorten duration of untreated psychosis: systematic review

BACKGROUND Long duration of untreated psychosis (DUP) is common and associated with poor outcomes. Strategies to enhance early detection of first-episode psychosis have been advocated. AIMS To evaluate initiatives for early detection of psychosis. METHOD Systematic review of available evidence on the effectiveness of early detection initiatives to reduce the DUP. RESULTS The review included 11 studies which evaluated 8 early detection initiatives. Evidence suggests that general practitioner education campaigns and dedicated early intervention services do not by themselves reduce DUP or generate more treated cases. Evidence for multifocus initiatives is mixed: intensive campaigns targeting the general public as well as relevant professionals may be needed. No studies evaluated initiatives targeting young people or professionals from non-health organisations. CONCLUSIONS How early detection can be achieved is not clear. Evidence is most promising for intensive public awareness campaigns: these require organisation and resourcing at a regional or national level. More good-quality studies are needed to address gaps in knowledge.

Continuity of care for the severely mentally ill : concepts and measures

Very few useful measures of service functioning are as yet available for the evaluation of mental health services. Continuity of care has been identified as “the strategic first choice” for the development of such process measures. The term “continuity” has been used to refer to a variety of important aspects of service functioning, including whether services maintain contact with patients, whether patients consistently see the same staff, success of transfer between services, degree to which plans for services are followed through, integration between service providers, and comprehensiveness in meeting patients individual needs. In this paper, we reviewed the main theoretical definitions of continuity of care for the severely mentally ill, and discussed the work that has attempted to operationalise these definitions and to apply them in the study of mental health services. We concluded that whilst continuity of care has had a central place in theoretical discussions of community service planning, progress in developing and applying practical measures has so far been sporadic and limited. Obstacles to such research have included great diversity in definitions of continuity and the confounding influence of individual patient characteristics on the relationship between service process and outcome. Despite these limitations, research in this field has indicated that developing and applying measures of continuity of care may be feasible and produce useful results, with findings of some of the studies suggesting a relationship between continuity of care and individual outcome.

The European Service Mapping Schedule (ESMS): development of an instrument for the description and classification of mental health services

Objective: This paper describes the development of an instrument for description and classification of mental health services and for measurement of service use. Purposes to be served by the instrument include: (i) identification of gaps in the spectrum of services in a catchment area; (ii) obtaining background information which may be important to understanding why apparently similar interventions lead to different outcomes in different areas; (iii) investigating how introduction of a particular type of service influences use of other local services; and (iv) understanding the relationship between sociodemographic factors and service use.

How does drug and alcohol misuse develop among people with psychotic illness? A literature review

Background: There is little evidence contributing to the understanding of why people with schizophrenia and other psychotic illnesses use drugs and alcohol. Method: A comprehensive literature search for evidence relevant to each of the following questions was undertaken, each of which is relevant to understanding why individuals with schizophrenia and other functional psychotic illnesses use drugs and alcohol: (1) Is substance misuse more prevalent among those with psychotic illness than the general Population? (2) Which problem generally develops first in dual diagnosis? (3) Can substance misuse cause schizophrenia and other functional psychotic illnesses? (4) Does dual diagnosis have a neurobiological Basis? (5) Is personality disorder a mediating factor in the relationship between psychotic illnesses and substance misuse? (6) Do individuals with psychotic illness use substances as self-medication? (7) Have changes in the care and social circumstances of people with psychotic illness, particularly deinstitutionalisation, led to a rise in substance misuse in this Population? (8) Do the social situations and social difficulties of people with psychotic illness lead to substance misuse? and (9) Do individuals with psychotic illness tend to begin using drugs and alcohol within mental health service settings or in the company of other users of such services? Results: There is some evidence to support the idea that people with schizophrenia and other psychotic disorders use substances to reduce general dysphoria, and possibly negative symptoms. Social environment and experiences are also likely to be factors in the development of substance misuse in this group, but there is a dearth of empirical evidence. Conclusions: There is a need for further research, especially concerning the social contexts of substance and alcohol misuse and the ways in which patterns of misuse develop among people with schizophrenia and other psychotic illnesses.

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK: A systematic review

BackgroundComorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such ‘dual diagnosis’. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.MethodsA literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.ResultsThere are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6–15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38–50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.ConclusionsRates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.

Improving support for mental health staff: a qualitative study

Background: High levels of both burnout and job satisfaction have been found in recent studies of mental health professionals. A qualitative methodology was used in a related study to explore reasons for these findings and to investigate staffs accounts of their strategies for coping with their work, and their views of support provided for them and how their jobs might be made less stressful and still more satisfying. Methods: A semi-structured schedule was used to interview a purposive sample of 30 mental health staff drawn from three South London geographical sectors, selected to include junior and senior members of each profession in both hospital and community settings. Interviews were transcribed and analysed using QSR NUD.IST software. Results: Informal contacts with colleagues were the most frequently mentioned way of coping with the difficult and demanding aspects of work in both hospital and community settings, closely followed by time management techniques. The main formal sources of support described by staff were individual supervision and staff support groups. Accounts of the former were generally positive, but there was great variation in opinions about whether support groups are useful. Almost all the interviewees believed that their jobs could be improved by further training. For community mental health staff the main training gaps were the development of skills in various forms of clinical intervention, whilst ward staff identified the need for further skills in diffusing potentially confrontational and aggressive situations.