Assessing the clinical and cost-effectiveness of inpatient mental health rehabilitation services provided by the NHS and independent sector (ACER): protocol.

BACKGROUND: Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people's homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness. METHODS: ACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners' experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is 'successful rehabilitation' defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months. DISCUSSION: The ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services. TRIAL REGISTRATION: ISRCTN17381762 retrospectively registered.

Exploring gender impact on collaborative care planning: insights from a community mental health service study in Italy.

INTRODUCTION: Personal recovery is associated with socio-demographic and clinical factors, and gender seems to influence the recovery process. This study aimed to investigate: i) differences in the recovery goals of men and women users of a community mental health service in Italy; ii) any differences by gender in recovery over six months using the Mental Health Recovery Star (MHRS). METHODS: Service users and staff completed the MHRS together at recruitment and six months later to agree the recovery goals they wished to focus on. Socio-demographic and clinical characteristics and ratings of symptoms (BPRS), needs (CAN), functioning (FPS), and functional autonomy (MPR) were collected at recruitment and six months follow-up. Comparisons between men and women were made using t-tests. RESULTS: Ten women and 15 men completed the MHRS with 19 mental health professionals. Other than gender, men and women had similar socio-demographic, and clinical characteristics at recruitment. Women tended to choose recovery goals that focused on relationships whereas men tended to focus on work related goals. At follow-up, both men and women showed improvement in their recovery (MHRS) and women were less likely to focus on relationship related goals, perhaps because some had found romantic partners. There were also gains for both men and women in engagement with work related activities. Ratings of functional autonomy (MPR) improved for both men and women, and men also showed improvement in symptoms (BPRS) and functioning (FPS). CONCLUSIONS: Our findings suggest that collaborative care planning tools such as the MHRS can assist in identifying individualized recovery goals for men and women with severe mental health problems as part of their rehabilitation.

Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

Supported employment for people with severe mental illness: a pilot study of an Italian social enterprise with a special ingredient.

BACKGROUND: People with mental disorders are far more likely to be unemployed than the general population. Two internationally recognized, evidence-based models of interventions for employment for people with severe mental health problems are Individual Placement Support and the Clubhouse. In Italy, a common model is the 'social enterprise' (SE), which is a programme run by non-profit organisations that help individuals with disabilities to be employed. Despite SEs spread and relevance in Italy, there are no studies about Italian samples. This paper reports on a pilot evaluation of psychosocial and work outcomes of a SE based in Verona, Italy. The study aims to investigate if people with SMI involved in SE job placements may achieve personal recovery and better outcomes over time, and in comparison with a comparable group of users. METHODS: This is a pilot descriptive study with three components. A longitudinal design that comprised a functioning description of 33 SE members with a psychiatric disability in two time-points (when they joined the SE-on average 5 years before the study recruitment, and at the study recruitment-year 2018); and a repeated collection of job details of the 33 members in three time points: 2 years before the recruitment,-year 2016; 1 year before the recruitment - year 2017; and at the recruitment-year 2018. An assessment at the recruitment time-year 2018, of SE users' satisfaction with the job placement, symptoms, functioning, and quality of life (QoL). A cross-sectional study that compared the 33 SE members at the recruitment time-year 2018, with a matched group of people with the following criteria: living in local supported accommodations, being unemployed and not SE members. The two groups were compared on ratings of psychopathology, functioning, and QoL. Descriptive analyses were done. RESULTS: At the recruitment time - year 2018, all SE participants showed a significant better functioning (p < 0.001) than when they joined the SE-when they had been employed for an average of 5 years. In comparison to the matched group, SE members had significantly better functioning (p = 0.001), psychopathology (p = 0.007), and QoL (p = 0.034). According to their SE membership status, participants comprised trainees (21.2%) and employee members (78.8%). Trainees compared to employees had lower autonomies, functioning, QoL and more severe psychopathology. Over the two years prior to study recruitment, trainees showed stable poor autonomies, while employee members showed a variation from average autonomies in the 2 years before the recruitment time - year 2016, to good ones at the recruitment time - year 2018. Over the two years, all SE members set increasing numbers of objectives in all three domains. All SE participants reported high levels of satisfaction with all aspects of the job placement. CONCLUSIONS: SE that provides tailored support to assist people to gain employment skills may be an effective component in helping recovery from SMI.

Quality of residential facilities in Italy: satisfaction and quality of life of residents with schizophrenia spectrum disorders.

BACKGROUND: Recovery and human rights promotion for people with Schizophrenia Spectrum Disorders (SSDs) is fundamental to provide good care in Residential Facilities (RFs). However, there is a concern about rehabilitation ethos in RFs. This study aimed to investigate the care quality of Italian RFs, the quality of life (QoL) and care experience of residents with SSD. METHODS: Fourty-eight RFs were assessed using a quality assessment tool (QuIRC-SA) and 161 residents with SSD were enrolled. Seventeen RFs provided high intensity rehabilitation (SRP1), 15 medium intensity (SRP2), and 16 medium-low level support (SRP3). Staff-rated tools measured psychiatric symptoms and psychosocial functioning; user-rated tools assessed QoL and satisfaction with services. RFs comparisons were made using ANOVA and Chi-squared. RESULTS: Over two-thirds patients (41.5 y.o., SD 9.7) were male. Seventy-six were recruited from SRP1 services, 48 from SRP2, and 27 from SRP3. The lowest QuIRC-SA scoring was Recovery Based Practice (45.8%), and the highest was promotion of Human Rights (58.4%). SRP2 had the lowest QuIRC-SA ratings and SRP3 the highest. Residents had similar psychopathology (p = 0.140) and functioning (p = 0.537). SRP3 residents were more employed (18.9%) than SRP1 (7.9%) or SRP2 (2.2%) ones, and had less severe negative symptoms (p = 0.016) and better QoL (p = 0.020) than SRP2 residents. There were no differences in the RF therapeutic milieu and their satisfaction with care. CONCLUSIONS: Residents of the lowest supported RFs in Italy had less severe negative symptoms, better QoL and more employment than others. The lowest ratings for Recovery Based Practice across all RFs suggest more work is needed to improve recovery.

IRP commission: sexual minorities and mental health: global perspectives.

Sexual orientation is a key determinant of the identity of human beings. It has also been seen as a social determinant of health. People whose sexual orientation is non-heterosexual or sexual minorities or sexually diverse are included in the broad umbrella term LGBT (Lesbian, Gay, Bisexual, and Transgender) which is a commonly used acronym in activism, social policy, and subsequently cultural literature. For this reason, this Commission focuses primarily on sexual orientation i.e. lesbian, gay and bisexual (LGB) groups. We have used terms non-heterosexual, sexual minorities or sexual variation interchangeably. We have not considered asexual individuals as research in the field is too limited. We are cognisant of the fact that topics relating to mental health and sexual orientation discussed in this Commission will intersect with other issues of personal, cultural and social identity, and will thus be relevant to individuals including many transgender individuals. The inclusion of mental health issues relevant to gender-diverse individuals as well as gender identity is important and deserves its own separate detailed discussion. The exact number of sexually diverse individuals in a population is often difficult to estimate but is likely to be somewhere around 5% of the population. Rates of various psychiatry disorders and suicidal ideation and acts of suicide in LGB populations are higher than general population and these have been attributed to minority stress hypothesis. Elimination of inequality in law can lead to reduction in psychiatric morbidity in these groups. However, these are all diverse groups but even within each group there is diversity and each individual has a distinct and unique experiences, upbringing, responses to their own sexual orientation, and generating varying responses from families, peers and friends as well as communities (including healthcare professionals). The mental healthcare needs of sexual minority individuals vary and these variations must be taken into account in design, development and delivery of healthcare and policies. Improving access to services will help engagement and outcomes and also reduce stigma. The commission recommends that there is no role for so-called conversion therapies and other recommendations are made for clinicians, researchers and policymakers.

Research into mental health supported accommodation - desperately needed but challenging to deliver.

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.

Predictors of successful move-on to more independent accommodation amongst users of the community mental health rehabilitation team: a prospective cohort study in inner London.

PURPOSE: In England, community mental health rehabilitation teams play a major role in supporting people with complex mental health needs to progress from inpatient to community settings and from more to less supported accommodation. We aimed to conduct the first study to investigate longitudinal outcomes for users of a community rehabilitation team and identify service user characteristics associated with successful progress along the rehabilitation pathway. METHODS: We used routinely collected clinical outcome data relating to all 193 users of a community rehabilitation team in inner London, transferred to the team between June 2013 and May 2018, with a cut-off data-collection date of 20th June 2019. We estimated the proportion who moved on to more independent accommodation successfully, with no breakdown in the placement. We conducted multivariable Cox proportional hazard regression to investigate associations between service user characteristics at transfer and successful move-on. RESULTS: Overall, 43/193 (23%) service users achieved successful move-on during a median follow-up of 51 months (IQR 32-63). This was more likely for those who were residing in more highly supported accommodation (HR 3.90; 95% CI 2.01-7.54) and those who had better functioning (HR 1.04, 95% CI 1.02-1.06) at transfer, while those with a serious physical health condition were less likely to achieve successful move-on (HR 0.44, 95% CI 0.21-0.95). CONCLUSION: Most supported accommodation services aim to offer time-limited support, but most service users do not progress successfully to more independent accommodation within 4 years. Investment in interventions that improve functioning and physical health may facilitate successful move-on.

Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff.

PURPOSE: The COVID-19 pandemic has potential to disrupt and burden the mental health care system, and to magnify inequalities experienced by mental health service users. METHODS: We investigated staff reports regarding the impact of the COVID-19 pandemic in its early weeks on mental health care and mental health service users in the UK using a mixed methods online survey. Recruitment channels included professional associations and networks, charities, and social media. Quantitative findings were reported with descriptive statistics, and content analysis conducted for qualitative data. RESULTS: 2,180 staff from a range of sectors, professions, and specialties participated. Immediate infection control concerns were highly salient for inpatient staff, new ways of working for community staff. Multiple rapid adaptations and innovations in response to the crisis were described, especially remote working. This was cautiously welcomed but found successful in only some clinical situations. Staff had specific concerns about many groups of service users, including people whose conditions are exacerbated by pandemic anxieties and social disruptions; people experiencing loneliness, domestic abuse and family conflict; those unable to understand and follow social distancing requirements; and those who cannot engage with remote care. CONCLUSION: This overview of staff concerns and experiences in the early COVID-19 pandemic suggests directions for further research and service development: we suggest that how to combine infection control and a therapeutic environment in hospital, and how to achieve effective and targeted tele-health implementation in the community, should be priorities. The limitations of our convenience sample must be noted.

Predictors of moving on from mental health supported accommodation in England: national cohort study.

BACKGROUND: 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. AIMS: A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Validity, reliability, acceptability, and utility of the Social Inclusion Questionnaire User Experience (SInQUE): a clinical tool to facilitate social inclusion amongst people with severe mental health problems.

BACKGROUND: Individuals with severe mental health problems are at risk of social exclusion, which may complicate their recovery. Mental health and social care staff have, until now, had no valid or reliable way of assessing their clients' social inclusion. The Social Inclusion Questionnaire User Experience (SInQUE) was developed to address this. It assesses five domains: social integration; productivity; consumption; access to services; and political engagement, in the year prior to first psychiatric admission (T1) and the year prior to interview (T2) from which a total score at each time point can be calculated. AIMS: To establish the validity, reliability, and acceptability of the SInQUE in individuals with a broad range of psychiatric diagnoses receiving care from community mental health services and its utility for mental health staff. METHOD: Participants were 192 mental health service users with psychosis, personality disorder, or common mental disorder (e.g., depression, anxiety) who completed the SInQUE alongside other validated outcome measures. Test-retest reliability was assessed in a sub-sample of 30 participants and inter-rater reliability was assessed in 11 participants. SInQUE ratings of 28 participants were compared with those of a sibling with no experience of mental illness to account for shared socio-cultural factors. Acceptability and utility of the tool were assessed using completion rates and focus groups with staff. RESULTS: The SInQUE demonstrated acceptable convergent validity. The total score and the Social Integration domain score were strongly correlated with quality of life, both in the full sample and in the three diagnostic groups. Discriminant validity and test-retest reliability were established across all domains, although the test-retest reliability on scores for the Service Access and Political Engagement domains prior to first admission to hospital (T1) was lower than other domains. Inter-rater reliability was excellent for all domains at T1 and T2. CONCLUSIONS: The component of the SInQUE that assesses current social inclusion has good psychometric properties and can be recommended for use by mental health staff.

Mental health supported accommodation services in England and in Italy: a comparison.

PURPOSE: England and Italy are considered pioneers in the development of community mental health services. Both have implemented supported accommodation services for those with more complex needs, which can be broadly categorized into three main types with similar specification. The aim of this study was to compare the characteristics of these services and their users in England and Italy. METHODS: Data from two cross-sectional surveys of supported accommodation services undertaken across England and in Verona, Italy (England-619 service users from 87 services; Verona-167 service users from 25 services) were compared. RESULTS: Service users in the two samples had similar socio-demographic and clinical characteristics; most were male, unmarried and unemployed, with a primary diagnosis of schizophrenia or other psychosis and over 15 years contact with mental health services. Supported accommodation occupancy was high in both samples. The actual length of stay was greater than the expected length of stay for all three service types but overall turnover was similar between countries (p = 0.070). Across services, total needs and quality of life were higher for Italian compared to English service users (p < 0.001 for both) but, unmet needs were lower amongst English service users (p < 0.001). Around 40% in both samples moved to more independent accommodation successfully within 30 months. CONCLUSIONS: England and Italy have similar mental health supported accommodation pathways to assist those with more complex needs to gain skills for community living, but individuals tend to require longer than expected at each stage.

Assessing needs for psychiatric treatment in prisoners: 3. Comparison of care received by black and minority ethnic prisoners and by white prisoners.

PURPOSE: To investigate to what extent mental health treatment needs are met in white and black and minority ethnic (BME) prisoners. METHODS: Treatment needs of a random sample of male (n = 197) and female (n = 171) prisoners were assessed with standardised instruments. Interventions provided were confirmed through face-to-face interviews and case note review. RESULTS: BME prisoners comprised 44% of participants. Treatment for depression, personality disorder and alcohol abuse was more often needed by White than BME prisoners. Needs were more frequently met in White than BME prisoners (48.5% vs 38.2%; p < 0.05), largely due to the delivery of psychological treatments. CONCLUSIONS: BME prisoners had fewer of their mental health needs met.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes.

BACKGROUND: Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services. METHODS: Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'. RESULTS: Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research. CONCLUSIONS: A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Predictors of quality of care in mental health supported accommodation services in England: a multiple regression modelling study.

BACKGROUND: Specialist mental health supported accommodation services are a key component to a graduated level of care from hospital to independently living in the community for people with complex, longer term mental health problems. However, they come at a high cost and there has been a lack of research on the quality of these services. The QuEST (Quality and Effectiveness of Supported tenancies) study, a five-year programme of research funded by the National Institute for Health Research, aimed to address this. It included the development of the first standardised quality assessment tool for supported accommodation services, the QuIRC-SA (Quality Indicator for Rehabilitative Care - Supported Accommodation). Using data collected from the QuIRC-SA, we aimed to identify potential service characteristics that were associated with quality of care. METHODS: Data collected from QuIRC-SAs with 150 individual services in England (28 residential care, 87 supported housing and 35 floating outreach) from four different sources were analysed using multiple regression modelling to investigate associations between service characteristics (local authority area index score, total beds/spaces, staffing intensity, percentage of male service users and service user ability) and areas of quality of care (Living Environment, Therapeutic Environment, Treatments and Interventions, Self-Management and Autonomy, Social Interface, Human Rights and Recovery Based Practice). RESULTS: The local authority area in which the service is located, the service size (number of beds/places) and the usual expected length of stay were each negatively associated with up to six of the seven QuIRC-SA domains. Staffing intensity was positively associated with two domains (Therapeutic Environment and Treatments and Interventions) and negatively associated with one (Human Rights). The percentage of male service users was positively associated with one domain (Treatments and Interventions) and service user ability was not associated with any of the domains. CONCLUSIONS: This study identified service characteristics associated with quality of care in specialist mental health supported accommodation services that can be used in the design and specification of services.

Quality of care in long-term care departments in mental health facilities across the Czech Republic.

Background: In the region of Central and Eastern Europe, long-term departments at psychiatric hospitals provide a large proportion of the care for people with complex mental health needs. The System of United Psychiatric Rehabilitation (S.U.P.R.) project focussed on the implementation of a complex set of interventions of psychosocial rehabilitation to increase the quality of care. The aim of this study was to assess the effect of the S.U.P.R. psychosocial rehabilitation programme on the quality of care at the longer-term inpatient psychiatric departments. Methods: All 12 psychiatric hospitals in the Czech Republic were asked to participate in the study. A 'before and after' design was adopted to evaluate the impact of the S.U.P.R. programme. Quality of care was assessed using the internationally validated, web-based tool, QuIRC (Quality Indicator for Rehabilitative Care), which provides percentage scores (0-100%) on seven domains of care and an overall mean quality score. Results: Fourteen long-term wards of 12 psychiatric hospitals for adults in the Czech Republic participated in the S.U.P.R. project. The mean total QuIRC scores were relatively low at the start of the project (range 33% to 53%) but all domain scores increased two years after the S.U.P.R. programme was implemented (range 44% to 62%). Staff feedback was generally positive about the programme, but inadequate staffing was an impediment to its success. Conclusion: Implementing a modern concept for psychosocial rehabilitation aimed at progressing the recovery of people with complex mental health problems can improve the quality of care in longer term inpatient settings.

Relationship between national mental health expenditure and quality of care in longer-term psychiatric and social care facilities in Europe: cross-sectional study.

BackgroundIt is not known whether increased mental health expenditure is associated with better outcomes.AimsTo estimate the association between national mental health expenditure and (a) quality of longer-term mental healthcare, (b) service users' ratings of that care in eight European countries.MethodNational mental health expenditure (per cent of health budget spent on mental health) was calculated from international sources. Multilevel models were developed to assess associations with quality of care and service user experiences of care using ratings of 171 facility managers and 1429 service users.ResultsSignificant positive associations were found between mental health spend and (a) six of seven quality of care domains; and (b) service user autonomy and experiences of care.ConclusionsGreater national mental health expenditure was associated with higher quality of care and better service user experience.

Assessing needs for psychiatric treatment in prisoners: 1. Prevalence of disorder.

BACKGROUND: High levels of psychiatric morbidity in prisoners have important implications for services. Assessing Needs for Psychiatric Treatment in Prisoners is an evaluation of representative samples of prisoners in a male and a female prison in London. This paper reports on the prevalence of mental disorders. In a companion paper, we describe how this translates into mental health treatment needs and the extent to which they have been met. METHODS: Prisoners were randomly sampled in a sequential procedure based on the Local Inmate Data System. We interviewed roughly equal numbers from the following groups: male remand; male sentenced prisoners (Pentonville prison); and female remand; female sentenced prisoners (Holloway prison). Structured assessments were made of psychosis, common mental disorders, PTSD, personality disorder and substance abuse. RESULTS: We interviewed 197 male and 171 female prisoners. Psychiatric morbidity in male and female, sentenced and remand prisoners far exceeded in prevalence and severity than in equivalent general population surveys. In particular, 12% met criteria for psychosis; 53.8% for depressive disorders; 26.8% for anxiety disorders; 33.1% were dependent on alcohol and 57.1% on illegal drugs; 34.2% had some form of personality disorder; and 69.1% had two disorders or more. Moreover, in the year before imprisonment, 25.3% had used mental health services. CONCLUSIONS: These rates of mental ill-health and their similarity in remand and sentenced prisoners indicate that diversion of people with mental health problems from the prison arm of the criminal justice system remains inadequate, with serious consequences for well-being and recidivism.