Follow-up study of people who misuse alcohol: reflections on methodology.

Background Considerable challenges exist for researchers attempting to monitor longitudinally the impact of any intervention on heavy drinkers, therefore they are often excluded from surveys. A particular challenge is the loss of validity through attrition. Aim To describe issues encountered when recruiting and re-contacting difficult to reach heavy drinkers participating in a longitudinal study; and propose strategies to inform the design of future studies to minimise the effects of confounding factors. Discussion Baseline recruitment exceeded targets, but attrition at first follow-up interview was considerable. Baseline alcohol consumption was not predictive of loss to follow-up. A variety of factors affected attrition including abstinence, severe intoxication at interview, deaths, selling of telephone, change of address and incarceration. Conclusion Longitudinal studies that use personal telephones or address details in following up heavy drinkers face considerable challenges to minimise attrition. An important mitigating factor is the use of flexible and experienced interviewers. Implications for practice The anticipated and reactive strategies documented in this paper provide important lessons for costing, designing and collecting data in future studies.

White cider consumption and heavy drinkers: a low-cost option but an unknown price.

AIMS: To compare characteristics of heavy drinkers who do, or do not, drink white cider during their typical drinking week and to contrast white cider drinkers' behaviour with a similar group recruited in comparable settings 4 years previously. To consider if excessive white cider consumption poses a specific health risk. METHODS: Cross-sectional survey of alcohol purchasing and consumption by heavy drinkers consuming white cider in Edinburgh and Glasgow during 2012; comparison of purchasing patterns within Edinburgh in 2008-2009 and 2012. Participants were 639 patients (in- and out-patient settings) with serious health problems linked to alcohol, 345 in Glasgow, 294 in Edinburgh in 2012, and 377 in Edinburgh in 2008-2009. RESULTS: In 2012 white cider consumption was reported by 25% of participants (median consumption (all alcohol) was 249 UK units per week-1 UK unit being 8 g of ethanol). They were more likely to be male and younger. They drank more units of alcohol than non-white cider drinkers and reported more alcohol-related problems. The median price paid for white cider in 2012 was 17 ppu. The period 2008-2012 was associated with decreasing affordability of alcohol, but consumption levels amongst the heaviest drinkers were maintained, associated with an increased proportion of units purchased as white cider. CONCLUSION: White cider makes an important contribution to the weekly intake of heavy drinkers in Scotland, likely facilitated by low price per unit of alcohol. We suggest these characteristics permit this drink to act as a buffer, supporting the continuation of a heavy drinking pattern when affordability of alcohol falls.

Long-term outcomes of the recovery approach in a high-security mental health setting: a 20 year follow-up study.

Background: This study examined the outcomes of a descriptive, longitudinal cohort consisting of 241 patients initially examined in a population study at the high secure State Hospital for Scotland and Northern Ireland in 1992-93. A partial follow-up focusing on patients with schizophrenia was conducted in 2000-01, followed by a comprehensive 20 year follow-up that began in 2014. Aims: To explore what happens to patients who required high secure care during a 20 year follow-up period. Method: Previously collected data were amalgamated with newly collected information to examine the recovery journey since baseline. Various sources were employed, including patient and keyworker interviews, case note reviews, and extraction from health and national records, and Police Scotland datasets. Results: Over half of the cohort (56.0%) with available data resided outside secure services at some point during the follow-up period (mean 19.2 years), and only 12% of the cohort were unable to transition out of high secure care. The symptoms of psychosis improved, with statistically significant reductions observed in reported delusions, depression, and flattened affect. Reported sadness [according to the Montgomery-Åsberg Depression Rating Scale (MADRS)] at baseline, first, and 20 year follow-up interviews was negatively correlated with the questionnaire about the process of recovery (QPR) scores at the 20 year follow-up. However, qualitative data depicted progress and personal development. According to societal measures, there was little evidence of sustained social or functional recovery. The overall conviction rate post-baseline was 22.7%, with 7.9% violent recidivism. The cohort exhibited poor morbidity and mortality, with 36.9% of the cohort dying, primarily from natural causes (91%). Conclusions: Overall, the findings showed positive outcomes in terms of movement out of high-security settings, symptom improvement, and low levels of recidivism. Notably, this cohort experienced a high rate of deaths and poor physical morbidity, along with a lack of sustained social recovery, particularly among those who had negotiated a path through services and who were current residents in the community. Social engagement, enhanced during residence in low secure or open ward settings, diminished significantly during the transition to the community. This is likely a result of self-protective measures adopted to mitigate societal stigma and the shift from a communal environment. Subjective depressive symptoms may impact broader aspects of recovery.

Understanding the mental health needs of Scotland's prison population: a health needs assessment.

Introduction: This study reports on an assessment of mental health needs among Scotland's prison population which aimed to describe the scale and nature of need as well as identify opportunities to improve upon the services available. The project was commissioned by the Scottish Government to ensure that future changes to the services available to support the mental health and wellbeing of people in prison would be evidence-based and person-centered. Methods: A standardized approach to health needs assessments was employed. The study was comprised of four phases. In phase I a rapid literature review was undertaken to gather evidence on the prevalence of mental health needs experienced by people in prison in the UK. In Phase II a multi-method and multi-informant national mapping exercise involving providers to all Scottish prisons was undertaken to describe the mental health services available, and any gaps in these services, for people in and leaving prison. In Phase III prevalence estimates of several mental health needs were derived for Scotland's current prison population, modeled from a national survey dataset of Scotland's community population using logistic regression. Finally in Phase IV, professional stakeholders and individuals with lived experience were interviewed to understand their experiences and insights on challenges to supporting the mental health and wellbeing of people in prison, and ideas on how these challenges could be overcome. Results: Evidence across the four phases of this needs assessment converged indicating that existing provision to support the mental health of people in prison in Scotland was considered inadequate to meet these needs. Barriers to effective partnership working for justice, health, social work and third sector providers appear to have led to inadequate and fragmented care, leaving prisoners without the support they need during and immediately following imprisonment. Conclusions: Joint and coordinated action from justice, health and social care, and third sector providers is needed to overcome enduring and structural challenges to supporting the mental health of people in prison. Eighteen evidence-based recommendations were proposed to the Scottish Government relating to the high-level and operational-level changes required to adequately meet the prison population's mental health needs.

Exploration of morbidity, suicide and all-cause mortality in a Scottish forensic cohort over 20 years.

BACKGROUND: Premature mortality among patients experiencing forensic care is high. This paper examines the morbidity and mortality of all Scottish high secure patients in 1992/1993 and followed up 20 years later through the context of recovery. AIMS: To explore morbidity and delineate which patients are at greatest risk of premature mortality. To assess the extent of suicide and unnatural deaths. To establish which factors, if any, appear protective. METHOD: Health and mortality data were extracted from national data-sets and death categorised as premature or post-expected age. Standardised mortality ratios were calculated to explore natural, unnatural and suicide deaths with Cox regression conducted to explore baseline demographics and premature death. RESULTS: During a mean follow-up of 21.1 years, 36.9% (n = 89) died, at an average age of 55.6 years. Of these, 70.8% (n = 63) died prematurely. Men lost on average 14.9 years and women 24.1 years of potential life. Five lives (5.6%) were lost by suicide and three (3.4%) by unnatural means. CONCLUSIONS: In contrast to other mainstream and forensic cohorts, high rates of suicide and accidental deaths were not apparent. Risk of premature mortality is high. A greater focus upon physical health by community and in-patient services is essential.

A protocol in action: Recovery approach for patients within high secure care: A 20+ year follow-up.

OBJECTIVES: A person-centred approach to recovery is increasingly represented within mainstream mental health literature. Little examination of recovery among forensic mental health patients is evidenced. This study plans to address that insufficiency. METHODS: This protocol paper details a novel approach to exploring recovery among a cohort of 241 patients detained under conditions of high secure care in Scotland during August 1992 to August 1993. Under discussion is the repurposing of previous research to circumnavigate length of inpatient stay commonly associated with forensic mental health care. The methodology adopted, while considering data leakage given the vulnerable participant group, will be discussed. RESULTS: Repurposing and extending previous research attempts to address the file cabinet effect with 85% of health care research being wasted and future uncertainty regarding research funding in a post-Brexit era. This is an ongoing study. Ethical, confidentiality, privacy issues, and permissions are considered within the methodology. CONCLUSIONS: Ethical arguments can be made for tracing and attempting contact with vulnerable groups under-represented in the literature. A well-considered methodology putting the focus on participant welfare and confidentiality at every step is essential. The reported methodology provides an opportunity to expand and re-examine previously collected data through a contemporary lens.

A teachable moment for the teachable moment? A prospective study to evaluate delivery of a workshop designed to increase knowledge and skills in relation to alcohol brief interventions (ABIs) amongst final year nursing and occupational therapy undergraduates.

The perceived value of Alcohol Brief Interventions as a tool to address alcohol misuse in Scotland has supported the establishment of a Health Improvement, Efficiency, Access and Treatment, HEAT: H4 Standard to deliver ABIs within certain health care settings. This requires that nursing, medical and allied health professionals are appropriately skilled to deliver these interventions. This study explores the knowledge and attitudes regarding alcohol misuse and related interventions among two cohorts of final year nursing and occupational therapy undergraduate students before, during and following participation in a workshop devoted to ABI delivery. While relatively good knowledge around recommended limits for daily consumption was evident, this did not translate into competence relating to drink unit content. Although there was overwhelming agreement for the role of each profession in ABI delivery, less than half of students in each cohort at the outset of the workshop agreed that they had the appropriate knowledge to advise patients about responsible drinking. In both cohorts, at the three month follow-up stage, this percentage had almost doubled. Newly qualified practitioners perceived a wider role for motivational interviewing, and endorsed interactive delivery of alcohol education throughout all levels of the curriculum.

The enigma of 'harmful' alcohol consumption: evidence from a mixed methods study involving female drinkers in Scotland.

BACKGROUND/AIMS: An appreciation of the drinking patterns of population subgroups may usefully inform tailored interventions. For this purpose, research has highlighted a need to better describe the drinking behaviour of UK women. This study aims to characterise the purchasing and consumption behaviour of female heavy, harmed, drinkers in contact with Scottish health services in two cities and to explore the factors that influence the link to harm. METHODS: Mixed methods study involving cross-sectional survey questionnaires and one-to-one interviews (5). The questionnaires documented (1) demographic data (including derived deprivation score), last week's (or 'typical' weekly) consumption (type, brand, volume, price, place of purchase), self-reported illnesses, and (2) Alcohol-Related Problem Questionnaire score. A total of 181 patients with serious health problems linked to alcohol were recruited within National Health Service (NHS) hospital clinics (in- and outpatient settings), in two Scottish cities during 2012. RESULTS: Median consumption was 157.6 UK units for the recorded week, with almost exclusive purchase from 'off-sale' retail outlets. Preferred drinks were white cider, vodka and white wine. Increasing problems was positively associated with drinking more in the week, being younger and belonging to Glasgow. CONCLUSION: For Scottish women, the current definition of 'harmful' consumption likely captures a fourfold variation in alcohol intake, with gender differences less apparent. While current alcohol-related harm is positively associated with dose and being younger, there is clear evidence of an influence of the less tangible 'Glasgow effect'. Future harm concerns are warranted by data relating to pattern, alcohol dose and cigarette use.