The socioeconomic context of stigma: examining the relationship between economic conditions and attitudes towards people with mental illness across European countries.

Introduction: Efforts to reduce the stigma associated with mental illness have intensified over the past 30 years with a particular focus on improving public attitudes. Difficult economic circumstances can be harmful to intergroup relations, but little is known about whether there is a relationship between socioeconomic conditions and attitudes towards people with mental illnesses. Methods: Random effects logistic regression modelling was employed to explore the relationship between individual financial circumstances, contextual socioeconomic factors and difficulty speaking to a person with a significant mental illness across European countries. Results: Lower GDP per capita and higher income inequality at the country level, alongside individual financial difficulties, were each associated with a greater likelihood of reporting difficulty speaking to a person with a significant mental illness. Discussion: Micro and macro-economic factors are associated with public attitudes towards people with mental illness across Europe. With prolonged economic instability predicted over the coming years in Europe it is important that these findings are taken into consideration when designing mental health and social policies, in order to safeguard the progress that has been made in reducing mental health stigma to date.

Hydrodynamic efficiency in sharks: the combined role of riblets and denticles.

We investigate the influence of smooth and ribletted shark skin on a turbulent boundary layer flow. Through laser Doppler anemometry (LDA) the role of riblets in combination with the shark skin denticle is established for the first time. Our results show that smooth denticles behave like a typical rough surface when exposed to an attached boundary layer. Drag is increased for the full range of tested dimensionless denticle widths,w+≈ 25-80, wherew+is the denticle width,w, scaled by the friction velocity,uτ, and the kinematic viscosity,ν. However, when riblets are added to the denticle crown we demonstrate there is a significant reduction in drag, relative to the smooth denticles. We obtain a modest maximum drag reduction of 2% for the ribletted denticles when compared to the flat plate, but when compared to the smooth denticles the difference in drag is in excess of 20% forw+≈ 80. This study enables a new conclusion that riblets have evolved as a mechanism to reduce or eliminate the skin friction increase due to the presence of scales (denticles). The combination of scales and riblets is hydrodynamically efficient in terms of skin-friction drag, while also acting to maintain flow attachment, and providing the other advantages associated with scales, e.g. anti-fouling, abrasion resistance, and defence against parasites.

The need for further oral health research surrounding the provision of dental treatment for people with drug dependency.

The aim of this article is to highlight the need for further research in providing dental care for people with drug dependency. The association between people who misuse substances and dental disease is widely known occurrence, yet there have been few studies conducted in the UK surrounding this issue due to the nature of the cohort. Further to this, there are a multitude of barriers to accessing/seeking dental care that exist for those with drug dependency. Going forward, there is a need for the development of a new service model where dental care is part of a multidisciplinary team working towards treating people with drug dependency in a holistic way.

Capital depreciation: The lack of recovery capital and post-release support for prisoners leaving the Drug Recovery Wings in England and Wales.

BACKGROUND: This article draws on the evaluation of the pilot Drug Recovery Wings (DRWs), which were introduced ten prisons in England and Wales, with the intention of delivering abstinence-focused drug recovery services. The DRW pilots can be seen as representing the extension of the recovery paradigm - so prevalent elsewhere in UK drug policy - to the prison system. This study aimed to provide a detailed account of DRW prisoners' expectations and experiences in the transition from prison to the community and explore the potential for 'doing recovery' in prison and on release. METHODS: In-depth, qualitative interviews were conducted in prison with 61 prisoners across six of the DRWs. Follow-up interviews six months after release were conducted with 21 prisoners and 26 'recovery supports' (people identified as being close to the prisoners). Data from one, other or both sources was available for 36 prisoners. All interviews were fully transcribed and coded. RESULTS: The majority of the 61 had long histories of alcohol and/or opiate dependence, childhood adversity, undiagnosed mental health problems and few educational qualifications. Nonetheless, many had long histories of employment - mostly in manual trades. The majority described themselves as being 'in recovery' at the time of the first interview in prison. While one of the main aims of the DRWs was to support prisoners' recovery journeys into the community, this aspect of their work did not materialize. Professional support at release was largely absent or, where present, ineffectual. Many were released street-homeless or to disordered and threatening hostels and night-shelters. Only three of the 36 were fully abstinent from drink and drugs at time of re-interview, although some had moderated their use. A substantial number had returned to pre-imprisonment levels of use, often with deeply damaging impacts on those around them. DISCUSSION AND CONCLUSIONS: This research suggests a fundamental contradiction between recovery and imprisonment. In large part, imprisonment serves to erode recovery capital while, at the same time, making psychoactive substances readily available. Looking to the future, every effort should be made to divert substance users from imprisonment in the first place. Where that fails, the primary aim should be to reduce the erosion of recovery capital during imprisonment: through family support work, providing proper housing, training and education opportunities and ensuring a graduated reintroduction of prisoners into the community.

The appropriateness of psychotropic medicines: an interview study of service users attending a substance misuse service in England.

Background Mental health problems are common in people with substance misuse problems. However, there is a paucity of evidence regarding prescribing of psychotropic medications for people with comorbid mental health and substance misuse problems. Objective To explore the views of service users attending an addiction service on the appropriateness of psychotropic medications prescribed for their co-existing mental health problems. Setting A specialist addiction service in the North of England. Method A phenomenological approach was adopted. Semi-structured interviews were conducted with twelve service users. Data were analysed using thematic framework analysis. Main outcome measure Service users' views concerning the appropriateness of their prescribed psychotropic medications. Results The following themes captured service users' views on the appropriateness of their medications: benefits from medicines, entitlement to medicines, and assessment and review. Service users mostly described benefits from their medications (including those prescribed outside guideline recommendations) and there was also an awareness of the adverse effects they experienced from them. It appears that people with substance misuse problems have a particularly strong sense of their own needs and seek to influence prescribing decisions. Service users further described varied practices regarding assessment and review of their medications with evidence of regular reviews while others identified suboptimal or inadequate practices. Conclusion Most service users described improved functioning as a result of their prescribed psychotropic medications. Prescriptions that are inappropriate in terms of their usual indications may well be justified if they assist in stabilising service users and moving them on to recovery.

Discrediting experiences: outcomes of eligibility assessments for claimants with psychiatric compared with non-psychiatric conditions transferring to personal independence payments in England.

BACKGROUND: Recent qualitative research suggests that changes to the way eligibility for welfare payments is determined in the UK may be detrimental to claimants with mental illnesses. No large-scale analysis has been undertaken to date.AimsTo examine differences between claimants with psychiatric conditions compared with non-psychiatric conditions in the number of claims disallowed following a personal independence payment (PIP) eligibility assessment for existing disability living allowance (DLA) claimants. METHOD: Administrative data on DLA claimants with psychiatric conditions transferring to PIP between 2013 and 2016 was compared with claimants with non-psychiatric conditions to explore differences in the number of claims disallowed following an eligibility assessment. RESULTS: Claimants with a mental illness were 2.40 (95% CI 2.36-2.44) times more likely to have their existing DLA entitlement removed following a PIP eligibility assessment than claimants with musculoskeletal conditions, neurological conditions and diabetes. CONCLUSIONS: PIP eligibility assessment outcomes show marked differences by health condition, raising questions as to whether the process is equitable.Declaration of interestNone.

Prescribers' views and experiences of assessing the appropriateness of prescribed medications in a specialist addiction service.

Background Mental and physical health problems are common in people with substance misuse problems and medications are often required in their management. Given the extent of prescribing for service users who attend specialist addiction services, it is important to consider how prescribers in this setting assess the appropriateness of service users' prescribed medications. Objective To explore prescribers' views and experiences of assessing the appropriateness of medications prescribed for service users coming in for treatment as well as the differences between prescribers. Setting A specialist addiction service in the North of England. Method A phenomenological approach was adopted. Semi-structured interviews were conducted with four nurse prescribers and eight doctors. Data were analysed using thematic framework analysis. Main outcome measure Prescribers' views and experiences of assessing the appropriateness of prescribed medications. Results Assessment of the appropriateness of prescribed medications involved reviewing medications, assessing risk, history-taking, involvement of service users, and comparing guideline adherence and 'successful' prescribing. Doctors and nurse prescribers assessed the appropriateness of medications they considered to be within their competency. Doctors provided support to nurse prescribers and general practitioners (GPs) when dealing with issues around prescribing. Conclusion Assessment of the appropriateness of prescribed medications is complex. The recent reduction in medical expertise in specialist addiction services may negatively impact on the clinical management of service users. It appears that there is a need for further training of nurse prescribers and GPs so they can provide optimal care to service users.

Youth social behaviour and network therapy (Y-SBNT): adaptation of a family and social network intervention for young people who misuse alcohol and drugs - a randomised controlled feasibility trial.

BACKGROUND: Family interventions appear to be effective at treating young people's substance misuse. However, implementation of family approaches in UK services is low. This study aimed to demonstrate the feasibility of recruiting young people to an intervention based on an adaptation of adult social behaviour and network therapy. It also sought to involve young people with experience of using substance misuse services in the research process. OBJECTIVES: To demonstrate the feasibility of recruiting young people to family and social network therapy and to explore ways in which young people with experience of using substance misuse services could be involved in a study of this nature. DESIGN: A pragmatic, two-armed, randomised controlled open feasibility trial. SETTING: Two UK-based treatment services for young people with substance use problems, with recruitment taking place from May to November 2014. PARTICIPANTS: Young people aged 12-18 years, newly referred and accepted for structured interventions for drug and/or alcohol problems. INTERVENTIONS: A remote, web-based computer randomisation system allocated young people to adapted youth social behaviour and network therapy (Y-SBNT) or treatment as usual (TAU). Y-SBNT participants were intended to receive up to six 50-minute sessions over a maximum of 12 weeks. TAU participants continued to receive usual care delivered by their service. MAIN OUTCOME MEASURES: Feasibility was measured by recruitment rates, retention in treatment and follow-up completion rates. The main clinical outcome was the proportion of days on which the main problem substance was used in the preceding 90-day period as captured by the Timeline Follow-Back interview at 3 and 12 months. RESULTS: In total, 53 young people were randomised (Y-SBNT, n = 26; TAU, n = 27) against a target of 60 (88.3%). Forty-two young people attended at least one treatment session [Y-SBNT 22/26 (84.6%); TAU 20/27 (74.1%)]; follow-up rates were 77.4% at month 3 and 73.6% at month 12. Data for nine young people were missing at both months 3 and 12, so the main clinical outcome analysis was based on 24 young people (92.3%) in the Y-SBNT group and 20 young people (74.1%) in the TAU group. At month 12, the average proportion of days that the main problem substance was used in the preceding 90 days was higher in the Y-SBNT group than in the TAU group (0.54 vs. 0.41; adjusted mean difference 0.13, 95% confidence interval -0.12 to 0.39; p = 0.30). No adverse events were reported. Seventeen young people with experience of substance misuse services were actively involved throughout the study. They informed key elements of the intervention and research process, ensuring that the intervention was acceptable and relevant to our target groups; contributing to the design of key trial documents, ideas for a new model of public involvement and this report. Two parents were also involved. CONCLUSIONS: The adapted intervention could be delivered in young people's services, and qualitative interviews found that Y-SBNT was acceptable to young people, family members and staff. Engagement of family and network members proved difficult within the intervention and research aspects. The study proved the feasibility of this work in routine services but outcome measurement based on narrow substance use variables may be limited and may fail to capture other important changes in wider areas of functioning for young people. Validation of the EuroQol-5 Dimensions for young people aged 12-18 years should be considered and flexible models for involvement of young people in research are required to achieve inclusive representation throughout all aspects of the research process. Although recommendation of a full trial of the Y-SBNT intervention compared with TAU is not supported, this study can inform future intervention development and UK research within routine addiction services. TRIAL REGISTRATION: Current Controlled Trials ISRCTN93446265. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 15. See the NIHR Journals Library website for further project information.

Examining an alcohol health worker service's patient coverage.

Alcohol health workers (AHWs) have been found to be effective at reducing alcohol-related hospital admissions, but there is still a paucity of evidence in keys areas. This was the first study to investigate what percentage of patients referred to an AHW service by alcohol screening tools are actually seen by the AHWs. The study-based in a large teaching hospital in the north of England-also investigated the impact of social deprivation on service usage. Research data came from a patient database and semi-structured interviews with AHWs. Further research is required to better understand the 'harm paradox' of patients' differential susceptibility to alcohol-related harm and how this might impact AHW service patient flow.

Acupuncture as an intervention to reduce alcohol dependency: a systematic review and meta-analysis.

BACKGROUND: Acupuncture has been widely used as a treatment for alcohol dependence. An updated and rigorously conducted systematic review is needed to establish the extent and quality of the evidence on the effectiveness of acupuncture as an intervention for reducing alcohol dependence. This review aimed to ascertain the effectiveness of acupuncture for reducing alcohol dependence as assessed by changes in either craving or withdrawal symptoms. METHODS: In this systematic review, a search strategy was designed to identify randomised controlled trials (RCTs) published in either the English or Chinese literature, with a priori eligibility criteria. The following English language databases were searched from inception until June 2015: AMED, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and PubMed; and the following Chinese language databases were similarly searched: CNKI, Sino-med, VIP, and WanFang. Methodological quality of identified RCTs was assessed using the Jadad Scale and the Cochrane Risk of Bias tool. RESULTS: Fifteen RCTs were included in this review, comprising 1378 participants. The majority of the RCTs were rated as having poor methodological rigour. A statistically significant effect was found in the two primary analyses: acupuncture reduced alcohol craving compared with all controls (SMD = -1.24, 95% CI = -1.96 to -0.51); and acupuncture reduced alcohol withdrawal symptoms compared with all controls (SMD = -0.50, 95% CI = -0.83 to -0.17). In secondary analyses: acupuncture reduced craving compared with sham acupuncture (SMD = -1.00, 95% CI = -1.79 to -0.21); acupuncture reduced craving compared with controls in RCTs conducted in Western countries (SMD = -1.15, 95% CI = -2.12 to -0.18); and acupuncture reduced craving compared with controls in RCTs with only male participants (SMD = -1.68, 95% CI = -2.62 to -0.75). CONCLUSION: This study showed that acupuncture was potentially effective in reducing alcohol craving and withdrawal symptoms and could be considered as an additional treatment choice and/or referral option within national healthcare systems.

Conspicuous by their abstinence: The limited engagement of heroin users in English and Welsh Drug Recovery Wings.

BACKGROUND: In recent years, an abstinence-focused, 'recovery' agenda has emerged in UK drug policy, largely in response to the perception that many opioid users had been 'parked indefinitely' on opioid substitution therapy (OST). The introduction of ten pilot 'Drug Recovery Wings' (DRWs) in 2011 represents the application of this recovery agenda to prisons. This paper describes the DRWs' operational models, the place of opiate dependent prisoners within them, and the challenges of delivering 'recovery' in prison. METHODS: In 2013, the implementation and operational models of all ten pilot DRWs were rapidly assessed. Up to three days were spent in each DRW, undertaking semi-structured interviews with a sample of 94 DRW staff and 102 DRW residents. Interviews were fully transcribed, and coded using grounded theory. Findings from the nine adult prisons are presented here. RESULTS: Four types of DRW were identified, distinguished by their size and selection criteria. Strikingly, no mid- or large-sized units regularly supported OST recipients through detoxification. Type A were large units whose residents were mostly on OST with long criminal records and few social or personal resources. Detoxification was rare, and medication reduction slow. Type B's mid-sized DRW was developed as a psychosocial support service for OST clients seeking detoxification. However, staff struggled to find such prisoners, and detoxification again proved rare. Type C DRWs focused on abstinence from all drugs, including OST. Though OST clients were not intentionally excluded, very few applied to these wings. Only Type D DRWs, offering intensive treatment on very small wings, regularly recruited OST recipients into abstinence-focused interventions. CONCLUSION: Prison units wishing to support OST recipients in making greater progress towards abstinence may need to be small, intensive and take a stepped approach based on preparatory motivational work and extensive preparation for release. However, concerns about post-release deaths will remain.

ADAPTA: A pilot randomised controlled trial of an alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting.

AIM: To examine the relative feasibility, acceptability, applicability, effectiveness and explore cost-effectiveness of a healthy living focused intervention (HL) compared to an alcohol-focused intervention (AF) for problem drinkers identified in hospital. METHODS: A pragmatic, randomised, controlled, open pilot trial. Feasibility and acceptability were measured by recruitment, attrition, follow-up rates and number of treatment sessions attended. Effectiveness was measured using the Alcohol Use Disorders Identification Test score at six months. Additional economic and secondary outcome measures were collected. RESULTS: Eighty-six participants were randomised and 72% (n=62) were retained in full participation. Forty-one participants attended at least one treatment session (48%). A greater proportion in the HL group attended all four treatment sessions (33% vs 19%). Follow-up rates were 29% at six months and 22% at twelve months. There was no evidence of a difference in AUDIT score between treatment groups at six months. Mean cost of health care and social services, policing and the criminal justice system use decreased while EQ-5D scores indicated minor improvement in both arms. However, this pilot trial was not powered to detect differences in either measure between groups. CONCLUSIONS: While no treatment effect was observed, this study demonstrated a potential to engage patients drinking at harmful or dependent levels in a healthy living intervention. However, recruitment proved challenging and follow-up rates were poor. Better ways need to be found to help these patients recognise the harms associated with their drinking and overcome the evident barriers to their engagement with specialist treatment.

A randomised controlled feasibility trial of family and social network intervention for young people who misuse alcohol and drugs: study protocol (Y-SBNT).

BACKGROUND: A growing body of research has identified family interventions to be effective in treating young people's substance use problems. However, despite this evidence, take-up of family-based approaches in the UK has been low. Key factors for this appear to include the resource-intensive nature of most family interventions which challenges implementation and delivery in many service settings and the cultural adaptation of approaches developed in the USA to a UK setting. This study aims to demonstrate the feasibility of recruiting young people to a specifically developed family- and wider social network-based intervention by testing an adapted version of adult social behaviour and network therapy (SBNT). METHODS: A pragmatic, randomised controlled, open feasibility trial delivered in two services for young people in the UK. Potential participants are aged 12-18 years referred for drug or alcohol problems to either service. The main purpose of this study is to demonstrate the feasibility of recruiting young people to a specifically developed family and social network-based intervention. The feasibility and acceptability of this intervention will be measured by recruitment rates, treatment retention, follow-up rates and qualitative interviews. The feasibility of training staff from existing services to deliver this intervention will be explored. Using this opportunity to compare the effectiveness of the intervention against treatment as usual, Timeline Follow-Back interviews will document the proportion of days on which the main problem substance was used in the preceding 90-day period at each assessment point. The economic component will examine the feasibility of conducting a full incremental cost-effectiveness analysis of the two treatments. The study will also explore and develop models of patient and public involvement which support the involvement of young people in a study of this nature. DISCUSSION: An earlier phase of work adapted social behaviour and network therapy (adult approach) to produce a purpose-designed youth version supported by a therapy manual and associated resources. This was achieved by consultation with young people with experience of services and professionals working in services for young people. This feasibility trial alongside ongoing consultations with young people will offer a meaningful understanding of processes of delivery and implementation. TRIAL REGISTRATION: ISRCTN93446265; Date ISRCTN assigned 31/05/2013.

A national study of acute hospital based alcohol health workers.

Alcohol health workers (AHWs) have been identified as an effective means of tackling alcohol-related hospital admissions. However, there is no understanding of the national coverage, or the extent and diversity of the services provided by hospital-based AHWs. Using a cross-sectional questionnaire, this is the first study to explore the current provision and remit of AHWs in acute hospitals across England.The data was analysed using SPSS. Significant differences were found with regards to the extent and diversity of AHW provision across England. This research provides a point of comparison for current and future hospital-based AHW provision.Further research is necessary to examine different 'service types', establish effective ways of working, and determine whether sources of funding could and should more accurately reflect the remit of hospital-based AHW roles.

Effect of reclassification of cannabis on hospital admissions for cannabis psychosis: a time series analysis.

BACKGROUND: The UK Misuse of Drugs Act (1971) divided controlled drugs into three groups A, B and C, with descending criminal sanctions attached to each class. Cannabis was originally assigned by the Act to Group B but in 2004, it was transferred to the lowest risk group, Group C. Then in 2009, on the basis of increasing concerns about a link between high strength cannabis and schizophrenia, it was moved back to Group B. The aim of this study is to test the assumption that changes in classification lead to changes in levels of psychosis. In particular, it explores whether the two changes in 2004 and 2009 were associated with changes in the numbers of people admitted for cannabis psychosis. METHOD: An interrupted time series was used to investigate the relationship between the two changes in cannabis classification and their impact on hospital admissions for cannabis psychosis. Reflecting the two policy changes, two interruptions to the time series were made. Hospital Episode Statistics admissions data was analysed covering the period 1999 through to 2010. RESULTS: There was a significantly increasing trend in cannabis psychosis admissions from 1999 to 2004. However, following the reclassification of cannabis from B to C in 2004, there was a significant change in the trend such that cannabis psychosis admissions declined to 2009. Following the second reclassification of cannabis back to class B in 2009, there was a significant change to increasing admissions. CONCLUSION: This study shows a statistical association between the reclassification of cannabis and hospital admissions for cannabis psychosis in the opposite direction to that predicted by the presumed relationship between the two. However, the reasons for this statistical association are unclear. It is unlikely to be due to changes in cannabis use over this period. Other possible explanations include changes in policing and systemic changes in mental health services unrelated to classification decisions.

An alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting (ADAPTA): study protocol for a randomized, controlled pilot trial.

BACKGROUND: Alcohol misuse is a major cause of premature mortality and ill health. Although there is a high prevalence of alcohol problems among patients presenting to general hospital, many of these people are not help seekers and do not engage in specialist treatment. Hospital admission is an opportunity to steer people towards specialist treatment, which can reduce health-care utilization and costs to the public sector and produce substantial individual health and social benefits. Alcohol misuse is associated with other lifestyle problems, which are amenable to intervention. It has been suggested that the development of a healthy or balanced lifestyle is potentially beneficial for reducing or abstaining from alcohol use, and relapse prevention. The aim of the study is to test whether or not the offer of a choice of health-related lifestyle interventions is more acceptable, and therefore able to engage more problem drinkers in treatment, than an alcohol-focused intervention. METHODS/DESIGN: This is a pragmatic, randomized, controlled, open pilot study in a UK general hospital setting with concurrent economic evaluation and a qualitative component. Potential participants are those admitted to hospital with a diagnosis likely to be responsive to addiction interventions who score equal to or more than 16 on the Alcohol Use Disorders Identification Test (AUDIT). The main purpose of this pilot study is to evaluate the acceptability of two sorts of interventions (healthy living related versus alcohol focused) to the participants and to assess the components and processes of the design. Qualitative research will be undertaken to explore acceptability and the impact of the approach, assessment, recruitment and intervention on trial participants and non-participants. The effectiveness of the two treatments will be compared at 6 months using AUDIT scores as the primary outcome measure. There will be additional economic, qualitative and secondary outcome measurements. DISCUSSION: Development of the study was a collaboration between academics, commissioners and clinicians in general hospital and addiction services, made possible by the Collaboration in Leadership in Applied Health Research and Care (CLAHRC) program of research. CLAHRC was a necessary vehicle for overcoming the barriers to answering an important NHS question--how better to engage problem drinkers in a hospital setting. TRIAL REGISTRATION: ISRCTN47728072.

The alcohol improvement programme: evaluation of an initiative to address alcohol-related health harm in England.

AIMS: The evaluation aimed to assess the impact of The Alcohol Improvement Programme (AIP). This was a UK Department of Health initiative (April 2008-March 2011) aiming to contribute to the reduction of alcohol-related harm as measured by a reduction in the rate of increase in alcohol-related hospital admissions (ARHAs). METHODS: The evaluation (March 2010-September 2011) used a mix of qualitative and quantitative methods to assess the impact of the AIP on ARHAs, to describe and assess the process of implementation, and to identify elements of the programme which might serve as a 'legacy' for the future. RESULTS: There was no evidence that the AIP had an impact on reducing the rise in the rate of ARHAs. The AIP was successfully delivered, increased the priority given to alcohol-related harm on local policy agendas and strengthened the infrastructure for the delivery of interventions. CONCLUSION: Although there was no measurable short-term impact on the rise in the rate of ARHAs, the AIP helped to set up a strategic response and a delivery infrastructure as a first, necessary step in working towards that goal. There are a number of valuable elements in the AIP which should be retained and repackaged to fit into new policy contexts.