Swaran P. Singh

Early intervention in psychosis

Early intervention in psychosis services produce better clinical outcomes than generic teams and are also cost-effective. Clinical gains made within such services are robust as long as the interventions are actively provided. Longer-term data show that some of these gains are lost when care is transferred back to generic teams. This paper argues that sustaining these early gains requires both a reappraisal of generic services and an understanding of the active ingredients of early intervention, which can be tailored for longer input in cases with poorer outcome trajectories.

Process, outcome and experience of transition from child to adult mental healthcare : multiperspective study

BACKGROUND Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). AIMS As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS. METHOD We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced. RESULTS Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health. CONCLUSIONS For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

Disengagement from mental health services. A literature review.

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Transition of care from child to adult mental health services: the great divide.

Purpose of review Adolescents with mental health problems often require transition of care from child and adolescent to adult mental health services. This review is a synthesis of current research and policy literature on transition to describe the barriers at the interface between child and adolescent mental health services and adult mental health services and outcomes of poor transition. Recent findings Adolescence is a risk period for emergence of serious mental disorders. Child and adolescent mental health services and adult mental health services use rigid age cut-offs to delineate service boundaries, creating discontinuities in provision of care. Adolescent mental health services are patchy across the world. Several recent studies have confirmed that problems occur during transition in diverse settings across several countries. In physical health, there are emerging models of practice to improve the process and outcomes of transition, but there is very little comparable literature in mental healthcare. Summary Poor transition leads to disruption in continuity of care, disengagement from services and is likely to lead to poorer clinical outcomes. Some young people, such as those with neurodevelopmental disorders and complex needs, are at a greater risk of falling through the care gap during transition. Services need robust and high-quality evidence on the process and outcomes of transition so that effective intervention strategies can be developed.

Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients

Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta‐analysis of the clinical factors associated with the suicide of psychiatric in‐patients.

First episode psychosis and employment: a review.

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

The attitudes of 'tomorrow's doctors' towards mental illness and psychiatry : changes during the final undergraduate year

To compare the efficacy of two teaching styles, didactic teaching and problem based learning, in producing enduring change in final‐year medical students’ attitudes towards psychiatry and mental illness.

Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study.

Objective To test the hypothesis that people taking anxiolytic and hypnotic drugs are at increased risk of premature mortality, using primary care prescription records and after adjusting for a wide range of potential confounders. Design Retrospective cohort study. Setting 273 UK primary care practices contributing data to the General Practice Research Database. Participants 34 727 patients aged 16 years and older first prescribed anxiolytic or hypnotic drugs, or both, between 1998 and 2001, and 69 418 patients with no prescriptions for such drugs (controls) matched by age, sex, and practice. Patients were followed-up for a mean of 7.6 years (range 0.1-13.4 years). Main outcome All cause mortality ascertained from practice records. Results Physical and psychiatric comorbidities and prescribing of non-study drugs were significantly more prevalent among those prescribed study drugs than among controls. The age adjusted hazard ratio for mortality during the whole follow-up period for use of any study drug in the first year after recruitment was 3.46 (95% confidence interval 3.34 to 3.59) and 3.32 (3.19 to 3.45) after adjusting for other potential confounders. Dose-response associations were found for all three classes of study drugs (benzodiazepines, Z drugs (zaleplon, zolpidem, and zopiclone), and other drugs). After excluding deaths in the first year, there were approximately four excess deaths linked to drug use per 100 people followed for an average of 7.6 years after their first prescription. Conclusions In this large cohort of patients attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.

Measuring pathways to care in first-episode psychosis: A systematic review

BACKGROUND Adequately understanding and measuring pathways to care is a prerequisite for early detection and effective treatment of first-episode psychosis. METHOD We conducted a systematic review of studies on pathways to care in first-episode psychosis to establish what measures currently exist to assess pathways in first-episode psychosis and to compare these measures. RESULTS We identified 15 studies which had used six different measures of pathways to care. Differences in aims, methodology and lack of psychometric data did not allow a direct comparison of pathways measures but certain common themes emerged. DISCUSSION Pathways to care in first-episode psychosis are diverse and varied. There is no measure with established psychometric properties that has been devised on a well-developed theoretical or conceptual framework and had its psychometric properties established. The conflict between exploring the patients narrative and journey through the healthcare system and developing an empirical measure of pathways with optimal outcomes has hindered the development of such a measure.

REDUCING DURATION OF UNTREATED PSYCHOSIS: CARE PATHWAYS TO EARLY INTERVENTION IN PSYCHOSIS SERVICES

BACKGROUND Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed. AIMS To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway. METHOD Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed. RESULTS A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP. CONCLUSIONS Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.