The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Practitioner Review: Continuity of mental health care from childhood to adulthood for youths with ADHD - who, how and when?

Many youths with attention-deficit/hyperactivity disorder (ADHD) experience significant long-term impairment and may develop concurrent mental and somatic health difficulties as adults. This is associated with burden and costs for the individual and society which could be prevented through continued support in youth. Yet, only few young people transition to adult mental health services for ongoing care in different countries worldwide. We provide an overview on current transition practices, highlighting the gaps in knowledge and the barriers to effective service transitioning, while considering the large geographical variation in available guidelines and service provision. For ease of use, this review is organized in a question-and-answer format covering different aspects of the transition process and considering both service users' and clinicians' perspectives. Consensus is needed to identify those that require continued care, the optimal timing to arrange transition, and the most suitable services. Finally, we discuss cost-effectiveness of transition practices, consider examples of best practice, and propose recommendations on how to improve transitional care, including the importance of service users' input into transition planning.

Five-year illness trajectories across racial groups in the UK following a first episode psychosis.

PURPOSE: Psychosis disproportionally affects ethnic minority groups in high-income countries, yet evidence of disparities in outcomes following intensive early intervention service (EIS) for First Episode Psychosis (FEP) is less conclusive. We investigated 5-year clinical and social outcomes of young people with FEP from different racial groups following EIS care. METHOD: Data were analysed from the UK-wide NIHR SUPEREDEN study. The sample at baseline (n = 978) included White (n = 750), Black (n = 71), and Asian (n = 157) individuals, assessed during the 3 years of EIS, and up to 2 years post-discharge (n = 296; Black [n = 23]; Asian [n = 52] and White [n = 221]). Outcome trajectories were modelled for psychosis symptoms (positive, negative, and general), functioning, and depression, using linear mixed effect models (with random intercept and slopes), whilst controlling for social deprivation. Discharge service was also explored across racial groups, 2 years following EIS. RESULTS: Variation in linear growth over time was accounted for by racial group status for psychosis symptoms-positive (95% CI [0.679, 1.235]), negative (95% CI [0.315, 0.783]), and general (95% CI [1.961, 3.428])-as well as for functioning (95% CI [11.212, 17.677]) and depressive symptoms (95% CI [0.261, 0.648]). Social deprivation contributed to this variance. Black individuals experienced greater levels of deprivation (p < 0.001, 95% CI [0.187, 0.624]). Finally, there was a greater likelihood for Asian (OR = 3.04; 95% CI [2.050, 4.498]) and Black individuals (OR = 2.47; 95% CI [1.354, 4.520]) to remain in secondary care by follow-up. CONCLUSION: Findings suggest variations in long-term clinical and social outcomes following EIS across racial groups; social deprivation contributed to this variance. Black and Asian individuals appear to make less improvement in long-term recovery and are less likely to be discharged from mental health services. Replication is needed in large, complete data, to fully understand disparities and blind spots to care.

The black hole of the transition process: dropout of care before transition age in adolescents.

Recent evidence confirms the risks of discontinuity of care when young people make a transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS), although robust data are still sparse. We aimed to identify when and how patients get lost to care during transition by tracking care pathways and identifying factors which influence dropping out of care during transition. This is a retrospective observational study of 760 patients who reached the transition age boundary within 12 months before transition time and being treated at CAMHS for at least during preceding 18 months. Data were collected at two time points: last visit to CAHMS and first visit to AHMS. Socio-demographic, clinical and service utilization variables on CAMHS treatment were collected. In the 12 months leading up to the transition boundary, 46.8% of subjects (n = 356) withdrew from CAHMS without further contact with AHMS, 9.3% withdrew from CAHMS but were referred to AHMS by other services, 29% were transferred from CAHMS to AHMS, 10% remained at CAHMS and 5% patients were transferred to alternative services. Fifty-six percent of subjects experience cessation of care before the transition age. The risk of dropout increases with shorter contact time in CAMHS, is greater in subjects without pharmacological treatment, and decreases in subjects with psychosis, bipolar disorder, eating disorders, mental retardation, and neurodevelopmental disorders. This study confirms that a large number of people drop out of care as they approach the CAMHS transition and experience discontinuity of care during this critical period.

Stairway to Heaven: A First-Person Account of Noesis.

ABSTRACT: Mystical and spiritual experiences have been reported throughout human history. Causal explanations for these range from psychopathology of mental illness, drugs such as hallucinogens, neurological disorders including temporal lobe epilepsy, and genuine mystical or spiritual awakening. There is a common core of phenomena in such experiences, as described both in historical accounts and recent research, but also evidence of cultural specificity. This article is a personal account of such an experience, which occurred in a postanesthetic state. A striking feature of the experience was noesis: a sense of revelation and complete understanding. I argue that while there must be a neural basis to these phenomena, it is difficult to reduce the subjective meaning of the experience purely to a brain dysfunction. Reconciling mechanism and meaning of such experiences remains a challenge for both neuroscience and philosophy.

Psychiatric hospital reform in low- and middle-income countries: a systematic review of literature.

PURPOSE: Psychiatric hospitals or mental asylums grew across the world in the colonial era. Despite concerns over quality of care and human rights violations, these hospitals continue to provide the majority of mental health care in most low- and middle-income countries (LMICs). We sought to review the evidence of reform of mental hospitals and associated patient outcomes. METHODS: We adopted an integrative review methodology by including experimental and non-experimental research. The review protocol was registered on PROSPERO (CRD42019130399). A range of databases and systematic hand searches were conducted by two independent reviewers. Research conducted between 1980 and May 2019, that focused on any aspect of reform in mental hospitals for adults (age 18 and upwards) with severe mental illness and published in English, were considered. RESULTS: 16 studies were included in the review. 12 studies met inclusion criteria, and four additional reports emerged from the hand search. Studies covered-India, China, South Africa, Grenada, Georgia, Sri Lanka, Argentina and Brazil. Key findings emphasise the role of judicial intervention as a critical trigger of reform. Structural reform composed of optimisation of resources and renovations of colonial structures to cater to diverse patient needs. Process reforms include changes in medical management, admission processes and a move from closed to open wards. Staff engagement and capacity building have also been used as a modality of reform in mental hospital settings. CONCLUSION: There is some documentation of reform in psychiatric hospitals. However, poor methodological quality and variation in approach and outcomes measured, make it challenging to extrapolate specific findings on process or outcomes of reform. Despite being integral service providers, psychiatric hospitals still do not adopt patient centric, recovery-oriented processes. Hence, there is an urgent need to generate robust evidence on psychiatric reform and its effect on patient outcomes.

"I'm just a long history of people rejecting referrals" experiences of young people who fell through the gap between child and adult mental health services.

The paediatric-adult split in mental health care necessitates young people to make a transition between services when they reach the upper end of child and adolescent mental health services (CAMHS). However, we know that this transition is often poor, and not all young people who require ongoing support are able to continue care in adult mental health services (AMHS). These young people are said to have fallen through the gap between services. This research aimed to explore the reasons why young people fall through the gap between CAMHS and AMHS, and what effect this has had on them and their families. Narrative interviews were conducted with 15 young people and 15 parents, representing 19 unique transition stories. Themes were identified collaboratively using thematic analysis. Reasons for falling through the gap were grouped into systemic problems and problems with the quality of care received. Effects of falling through the gap were grouped into separate themes for young people (feeling abandoned; struggling to manage without continued care; problems with medication) and parents (emotional impact of care ending; parents taking an active role in the young person's care). To our knowledge, this is the first qualitative study that has focused only on the experiences of young people who have fallen through the gap between services. This research adds novel findings to existing literature regarding barriers to transition and the effects of discontinuity of care.

Challenges and Facilitators During Transitions from Adolescent Medium Secure Units to Adult Services in England: Interviews with Mental Healthcare Professionals.

Young people moving from child and adolescent secure hospitals present with complex needs and vulnerabilities and are more likely to experience poor transition outcomes. Previous research has indicated the presence of several risk factors in periods of transition, such as poor liaison among services, lack of proper planning, shortage of beds in adult services, multiple transitions and lack of emotional readiness. However, little evidence exists about the processes and outcomes of transitions from adolescent secure services to adult settings. This study aims to bridge the gap in the existing literature by exploring the views and experiences of key professionals involved in the transition process from six adolescent medium secure units to nine adult secure and community services in England. Thirty-four key workers from 15 child and adolescent (N = 21) and adult (N = 13) forensic hospitals were interviewed to provide information about potential barriers and facilitators to transitions. Face-to-face semi-structured interviews were conducted between January 2016 and December 2017. Thematic analysis was used to identify challenges and facilitators to transitions. Three primary themes were identified: (1) transition processes and preparation; (2) transition barriers and challenges; (3) success factors to transition. Key differences in adult and adolescent service care-models and lack of emotional and developmental readiness to moving onto adult-oriented settings constitute major barriers to positive transition outcomes. Practice and policy implications are considered to address the need for service transformations.

The prevalence of personality disorders in the community: a global systematic review and meta-analysis.

BACKGROUND: Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders. AIMS: To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs). METHOD: We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094). RESULTS: A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1-9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9-11.3%) compared with LMICs (4.3%, 95% CI 2.6-6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%). CONCLUSIONS: Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Transition as a topic in psychiatry training throughout Europe: trainees' perspectives.

The majority of adolescents with mental health problems do not experience continuity of care when they reach the transition boundary of their child and adolescent mental health service. One of the obstacles for a smooth transition to adult mental health services concerns the lack of training for health-care professionals involved in the transition process. This study aims to seek psychiatric trainees' opinions regarding training on transition and the knowledge and skills required for managing transition. A survey was distributed to trainees residing in European countries. Trainees from 36 countries completed the questionnaire, of which 63% reported that they came into contact with youth and young adults (16-26 years) during their clinical practice. Twenty-seven percent of trainees stated they have good to very good knowledge about the transition process. Theoretical training about transition was reported in only 17% of the countries, and practical training in 28% of the countries. Ninety-four percent of trainees indicated that further training about transition is necessary. The content of subsequent transition-related training can be guided by the findings of the MILESTONE project.

Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition.

BACKGROUND: Poor transitions to adult care from child and adolescent mental health services may increase the risk of disengagement and long-term negative outcomes. However, studies of transitions in mental health care are commonly difficult to administer and little is known about the determinants of successful transition. The persistence of health inequalities related to access, care, and outcome is now well accepted including the inverse care law which suggests that those most in need of services may be the least likely to obtain them. We sought to examine the pathways and determinants of transition, including the role of social class. METHOD: A retrospective systematic examination of electronic records and case notes of young people eligible to transition to adult care over a 4-year period across five Health and Social Care NHS Trusts in Northern Ireland. RESULTS: We identified 373 service users eligible for transition. While a high proportion of eligible patients made the transition to adult services, very few received an optimal transition process and many dropped out of services or subsequently disengaged. Clinical factors, rather than social class, appear to be more influential in the transition pathway. However, those not in employment, education or training (NEET) were more likely (OR 3.04: 95% CI 1.34, 6.91) to have been referred to Adult Mental Health Services (AMHS), as were those with a risk assessment or diagnosis (OR 4.89: 2.45, 9.80 and OR 3.36: 1.78, 6.34), respectively. CONCLUSIONS: Despite the importance of a smoother transition to adult services, surprisingly, few patients experience this. There is a need for stronger standardised policies and guidelines to ensure optimal transitional care to AMHS. The barriers between different arms of psychiatry appear to persist. Joint working and shared arrangements between child and adolescent and adult mental health services should be fostered.

Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review.

When young people reach the upper age limit of child and adolescent mental health services (CAMHS), care should be transferred to an adult mental health service (AMHS) if they require ongoing support. However, many young people experience a significant disruption of their care during this transition, whilst others may fail to transition at all. Currently, there is no systematic appraisal of the international evidence regarding the outcomes of young people after transition. A systematic review was conducted which aimed to synthesise and review the existing research regarding outcomes after transition. We searched six databases from their inception until December 2017 for research relating to either the mental health or service use outcomes of young people after reaching their CAMHS age boundary. Results were synthesised narratively. The initial searches identified 18,287 papers, of which 213 were screened on full text. 13 papers were included in the review, representing 10 cohorts of young people who crossed the transition age boundary. No studies contained extractable data on mental health outcomes following transition, and therefore, this review focused only on service use outcomes. Results showed a quarter of young people transitioned to AMHS, with the other young people experiencing varied outcomes after leaving CAMHS and multiple transitions during this time. This review provides evidence for the varying service use outcomes of young people after reaching the upper age limit of CAMHS. However, longitudinal research into long-term outcomes is lacking, in addition to research regarding the mental health and functioning outcomes of young people following transition.Protocol registration The protocol for this systematic review has been registered with PROSPERO, ID number CRD42018085916.

Can curriculum design influence medical students' attitudes to psychiatry? A comparison of two different approaches.

Medical students with poor attitudes toward psychiatry are unlikely to choose it as a career, and current psychiatry recruitment is inadequate for future NHS needs. Amending medical school curricula has been suggested as one solution. We performed a unique naturalistic mixed-methods cross-sectional survey of two sequential cohorts in a UK medical school, before and after the restructuring of the entire MBChB curriculum. As well as increasing integration with other specialties, the emphasis placed on psychiatry increased throughout the course, but the final psychiatry block reduced from 8 to 6 weeks. Students experiencing the refreshed curriculum had better attitudes to psychiatry and psychiatric patients and were more positive about psychiatry as a career for themselves and others, compared to students on the old curriculum. This was demonstrated both quantitatively using validated rating scales (12/30 questions ATP-30 and 1/6 questions PEAK-6) and qualitatively using free-text responses. Restructuring undergraduate medical curricula to enhance integration may yield added value, including the potential to improve attitudes to specialties previously learned in silos, such as psychiatry. This may improve recruitment and the understanding of mental health for all future doctors.

Training of adult psychiatrists and child and adolescent psychiatrists in europe: a systematic review of training characteristics and transition from child/adolescent to adult mental health services.

BACKGROUND: Profound clinical, conceptual and ideological differences between child and adult mental health service models contribute to transition-related discontinuity of care. Many of these may be related to psychiatry training. METHODS: A systematic review on General Adult Psychiatry (GAP) and Child and Adult Psychiatry (CAP) training in Europe, with a particular focus on transition as a theme in GAP and CAP training. RESULTS: Thirty-four full-papers, six abstracts and seven additional full text documents were identified. Important variations between countries were found across several domains including assessment of trainees, clinical and educational supervision, psychotherapy training and continuing medical education. Three models of training were identified: i) a generalist common training programme; ii) totally separate training programmes; iii) mixed types. Only two national training programs (UK and Ireland) were identified to have addressed transition as a topic, both involving CAP exclusively. CONCLUSION: Three models of training in GAP and CAP across Europe are identified, suggesting that the harmonization is not yet realised and a possible barrier to improving transitional care. Training in transition has only recently been considered. It is timely, topical and important to develop evidence-based training approaches on transitional care across Europe into both CAP and GAP training.

A realist approach to the evaluation of complex mental health interventions.

Conventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.Declaration of interestAll authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Department of Health. S.P.S. is part funded by Collaboration for Leadership in Applied Health Research and Care West Midlands. K.B. is editor of the British Journal of Psychiatry.

Correction to: The interface between child/adolescent and adult mental health services: results from a European 28­country survey.

The original version of this article contained an error in Table 1. The correct table is presented below.

The interface between child/adolescent and adult mental health services: results from a European 28-country survey.

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

What influences social outcomes among offenders with personality disorder: A systematic review.

BACKGROUND: Personality disorder is highly prevalent in offender populations and is associated with poor health, criminal justice, and social outcomes. Research has been conducted into factors that influence offending and health, but, in order to improve (re)habilitation, service providers must also be able to identify the variables associated with social outcomes and the mechanisms by which they operate. AIM: To establish what is known about what influences social outcomes among offenders with personality disorder. METHOD: A systematic review was completed using Cochrane methods, expanded to include nonrandomised trials. Anticipated high heterogeneity informed a narrative synthesis. RESULTS: Three studies met inclusion criteria. Two were qualitative studies including only 13 cases between them. All studies were low quality. CONCLUSIONS: There is insufficient evidence to determine what influences good social outcomes among offenders with personality disorder. Research is required to identify associated variables, to inform the development of effective interventions.

Integrated (one-stop shop) youth health care: best available evidence and future directions.

Although mental health problems represent the largest burden of disease in young people, access to mental health care has been poor for this group. Integrated youth health care services have been proposed as an innovative solution. Integrated care joins up physical health, mental health and social care services, ideally in one location, so that a young person receives holistic care in a coordinated way. It can be implemented in a range of ways. A review of the available literature identified a range of studies reporting the results of evaluation research into integrated care services. The best available data indicate that many young people who may not otherwise have sought help are accessing these mental health services, and there are promising outcomes for most in terms of symptomatic and functional recovery. Where evaluated, young people report having benefited from and being highly satisfied with these services. Some young people, such as those with more severe presenting symptoms and those who received fewer treatment sessions, have failed to benefit, indicating a need for further integration with more specialist care. Efforts are underway to articulate the standards and core features to which integrated care services should adhere, as well as to further evaluate outcomes. This will guide the ongoing development of best practice models of service delivery.

How effective are interventions to improve social outcomes among offenders with personality disorder: a systematic review.

BACKGROUND: Offenders with personality disorder are supported by health, criminal justice, social care and third sector services. These services are tasked with reducing risk, improving health and improving social outcomes. Research has been conducted into interventions that reduce risk or improve health. However, interventions to improve social outcomes are less clearly defined. METHODS: To review the effectiveness of interventions to improve social outcomes we conducted a systematic review using Cochrane methodology, expanded to include non-randomised trials. Anticipated high heterogeneity of the studies informed narrative synthesis. RESULTS: Eleven studies met inclusion criteria. Five contained extractable data. No high-quality studies were identified. Outcomes measured clustered around employment and social functioning. Interventions vary and their mechanisms for influencing social outcomes are poorly operationalised. Although change was observed in employment rates, there was no evidence for the effectiveness of these interventions. CONCLUSIONS: There is a lack of evidence for effective interventions that improve social outcomes. Further research is recommended to reach consensus on the outcomes of importance, identify the factors that influence these and design theoretically-informed and evidence-based interventions.