Estimating the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a real-world evaluation.

BACKGROUND: Addressing the wider determinants of mental health alongside psychological therapy could improve mental health service outcomes and population mental health. OBJECTIVES: To estimate the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) mental health service compared with traditional IAPT in England. Alongside traditional therapy treatment, the enhanced service included well-being support and community service links. DESIGN: A real-world evaluation using IAPT's electronic health records. SETTING: Three National Health Service IAPT services in England. PARTICIPANTS: Data from 17 642 service users classified as having a case of depression and/or anxiety at baseline. INTERVENTION: We compared the enhanced IAPT service (intervention) to an IAPT service in a different region providing traditional treatment only (geographical control), and the IAPT service with traditional treatment before additional support was introduced (historical control). PRIMARY OUTCOME MEASURES: Patient Health Questionnaire-9 (PHQ-9) Depression Scale (score range: 0-27) and Generalised Anxiety Disorder-7 (GAD-7) Anxiety Scale (score range: 0-21); for both, lower scores indicate better mental health. Propensity scores were used to estimate inverse probability of treatment weights, subsequently used in mixed effects regression models. RESULTS: Small improvements (mean, 95% CI) were observed for PHQ-9 (depression) (-0.21 to -0.32 to -0.09) and GAD-7 (anxiety) (-0.23 to -0.34 to -0.13) scores in the intervention group compared with the historical control. There was little evidence of statistically significant differences between intervention control and geographical control. CONCLUSIONS: Embedding additional health and well-being (H&W) support into standard IAPT services may lead to improved mental health outcomes. However, the lack of improved outcomes compared with the geographical control may instead reflect a more general improvement to the intervention IAPT service. It is not clear from our findings whether an IAPT service with additional H&W support is clinically superior to traditional IAPT models.

Public perspectives on inequality and mental health: A peer research study.

INTRODUCTION: Associations between structural inequalities and health are well established. However, there is limited work examining this link in relation to mental health, or that centres public perspectives. This study explores people's experience and sense-making of inequality in their daily lives, with particular consideration of impacts on mental health. METHODS: We conducted a peer research study. Participants had to live in one of two London Boroughs and have an interest in inequalities and mental health. Using social media, newsletters, local organisations and our peer researchers' contacts, we recruited 30 participants who took photos representing their experience of inequality and discussed them during semi-structured interviews. Data were analysed using reflexive thematic analysis. RESULTS: Three themes were identified in this study: (1) inequalities are unjust, multilayered and intertwined with mental health. Accounts demonstrated a deep understanding of inequalities and their link to mental health outcomes, describing inequalities as 'suffering' and 'not good for anyone'. Financial, housing, immigration and healthcare problems exacerbated poor mental health, with racism, gender-based violence and job loss also contributing factors for both poor mental health and experiences of inequality; (2) inequalities exclude and have far-reaching mental health consequences, impacting personal sense of belonging and perceived societal value and (3) moving forwards-addressing long-standing inequality and poor public mental health necessitated coping and resilience strategies that are often unacknowledged and undervalued by support systems. CONCLUSION: Lived experience expertise was central in this study, creating an innovative methodological approach. To improve public mental health, we must address the everyday, painful structural inequalities experienced by many as commonplace and unfair. New policies and strategies must be found that involve communities, redistributing resources and power, building on a collective knowledge base, to coproduce actions combatting inequalities and improving population mental health. PATIENT OR PUBLIC CONTRIBUTION: This study was peer-led, designed and carried out by researchers who had experiences of poor mental health. Six authors of the paper worked as peer researchers on this study.

Integrating Health into Local Plans: A Comparative Review of Health Requirements for Urban Development in Seven Local Planning Authorities in England.

A local plan is a statutory policy document that supports urban development decisions across a local government area in England. Local plans are reported to need more specific requirements for development proposals regarding wider health determinants to address potential health outcomes and health inequalities. This study reviews the integration of Health in Local Plans of seven local planning authorities through documentary analysis methods. A review framework was formulated based on health and planning literature regarding local plans, health policy and determinants of health and dialogue with a local government partner. The findings identify opportunities to strengthen the consideration of Health in Local Plans, including ensuring that policies are informed by local health priorities and signpost national guidance, strengthening health-related requirements for developers (e.g., indoor air quality, fuel poverty and security of tenure) and improving implementation of requirements for developers (e.g., through adoption of health management plans and community ownership). The study identifies further research needs regarding how policies are interpreted by developers in practice, and on national guidance for Health Impact Assessment. It highlights the benefit of undertaking a comparative review, contrasting local plan policy language and identifying opportunities to share, adapt and strengthen planning requirements regarding health outcomes.

Wellbeing in Secondary Education (WISE) Study to Improve the Mental Health and Wellbeing of Teachers: A Complex System Approach to Understanding Intervention Acceptability.

Teaching staff report poorer mental health and wellbeing than the general working population. Intervention to address this issue is imperative, as poor wellbeing is associated with burnout, presenteeism, and adverse student mental health outcomes. The Wellbeing in Secondary Education (WISE) intervention is a secondary school-based programme aimed at improving the mental health and wellbeing of teachers and students. There are three components: awareness-raising for staff; a peer support service delivered by staff trained in Mental Health First Aid (MHFA); and Schools and Colleges Mental Health First Aid (MHFA) training for teachers. A cluster randomised controlled trial with integrated process and economic evaluation was conducted with 25 secondary schools in the UK (2016-2018). The intervention was largely ineffective in improving teacher mental health and wellbeing. This paper reports process evaluation data on acceptability to help understand this outcome. It adopts a complex systems perspective, exploring how acceptability is a dynamic and contextually contingent concept. Data sources were as follows: interviews with funders (n = 3); interviews with MHFA trainers (n = 6); focus groups with peer supporters (n = 8); interviews with headteachers (n = 12); and focus groups with teachers trained in Schools and Colleges MHFA (n = 7). Results indicated that WISE intervention components were largely acceptable. Initially, the school system was responsive, as it had reached a 'tipping point' and was prepared to address teacher mental health. However, as the intervention interacted with the complexities of the school context, acceptability became more ambiguous. The intervention was seen to be largely inadequate in addressing the structural determinants of teacher mental health and wellbeing (e.g. complex student and staff needs, workload, and system culture). Future teacher mental health interventions need to focus on coupling skills training and support with whole school elements that tackle the systemic drivers of the problem.

What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review.

Mental health (MH) difficulties are on the increase among children and young people (CYP). Evidence has shown that educational settings contain both risk and protective factors for MH. This review investigated which structural and cultural factors and interventions within educational settings promote positive MH and prevent poor MH in 4-18 year olds. Searches were conducted in PsychINFO, Embase, ERIC, ASSIA and British Education Index, and reference lists from key studies and relevant systematic reviews were hand-searched. Intervention, cohort, and qualitative studies were included. Of the 62 included papers, 36 examined cultural factors (30 social/relational and six value-related) while 12 studies examined structural factors (eight organisational and four physical) and 14 studies examined multiple factors. There was strong evidence for the impact of positive classroom management techniques, access to physical activity, and peer mentoring on student MH. Studies examining the impact of positive school culture, teacher training in MH and parent involvement in school MH activities also found predominantly positive results for student MH, albeit the evidence was of lower quality or from a low number of studies. Few studies explicitly examined the impact of interventions on MH inequalities; those that did indicated limited if any reduction to inequalities. A very small number of studies suggested that interventions targeting those at risk of poor MH due to socioeconomic factors could successfully improve wellbeing and reduce depression, anxiety and behavioural problems. Studies exploring the effect of management and leadership strategies within schools, policies, and aspects of the physical environment other than green space were scarce or absent in the literature. This review highlights the need to consider the ways in which educational settings are organised, the culture that is created and the physical space in order to improve the MH of CYP.

Pandemics, vulnerability, and prevention: time to fundamentally reassess how we value and communicate risk?: CITIES, HEALTH and COVID-19: Initial reflections and future challenges.

For over a decade, pandemics have been on the UK National Risk Register as both the likeliest and most severe of threats. Non-infectious 'lifestyle' diseases were already crippling our healthcare services and our economy. COVID-19 has exposed two critical vulnerabilities: firstly, the UK's failure to adequately assess and communicate the severity of non-communicable disease; secondly, the health inequalities across our society, due not least to the poor quality of our urban environments. This suggests a potentially disastrous lack of preventative action and risk management more generally, notably with regards to the existential risks from the climate and ecological crises.

Protocol for a cluster randomised controlled trial of an intervention to improve the mental health support and training available to secondary school teachers - the WISE (Wellbeing in Secondary Education) study.

BACKGROUND: Teachers are reported to be at increased risk of common mental health disorders compared to other occupations. Failure to support teachers adequately may lead to serious long-term mental disorders, poor performance at work (presenteeism), sickness absence and health-related exit from the profession. It also jeopardises student mental health, as distressed staff struggle to develop supportive relationships with students, and such relationships are protective against student depression. A number of school-based trials have attempted to improve student mental health, but these have mostly focused on classroom based approaches and have failed to establish effectiveness. Only a few studies have introduced training for teachers in supporting students, and none to date have included a focus on improving teacher mental health. This paper sets out the protocol (version 4.4 20/07/16) for a study aiming to address this gap. METHODS: Cluster randomised controlled trial with secondary schools as the unit of randomisation. Intervention schools will receive: i) Mental Health First Aid (MHFA) training for a group of staff nominated by their colleagues, after which they will set up a confidential peer support service for colleagues ii) training in MHFA for schools and colleges for a further group of teachers, which will equip them to more effectively support student mental health iii) a short mental health awareness raising session and promotion of the peer support service for all teachers. Comparison schools will continue with usual practice. The primary outcome is teacher wellbeing measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). Secondary outcomes are teacher depression, absence and presenteeism, and student wellbeing, mental health difficulties, attendance and attainment. Measures will be taken at baseline, one year follow up (teachers only) and two year follow up. Economic and process evaluations will be embedded within the study. DISCUSSION: This study will establish the effectiveness and cost-effectiveness of an intervention that supports secondary school teachers' wellbeing and mental health, and improves their skills in supporting students. It will also provide information regarding intervention implementation and sustainability. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered 24/03/16.

A pilot cluster randomised controlled trial of a support and training intervention to improve the mental health of secondary school teachers and students - the WISE (Wellbeing in Secondary Education) study.

BACKGROUND: Secondary school teachers are at heightened risk of psychological distress, which can lead to poor work performance, poor quality teacher-student relationships and mental illness. A pilot cluster randomised controlled trial (RCT) - the WISE study - evaluated the feasibility of a full-scale RCT of an intervention to support school staff's own mental health, and train them in supporting student mental health. METHODS: Six schools were randomised to an intervention or control group. In the intervention schools i) 8-9 staff received Mental Health First Aid (MHFA) training and became staff peer supporters, and ii) youth MHFA training was offered to the wider staff body. Control schools continued with usual practice. We used thematic qualitative data analysis and regression modelling to ascertain the feasibility, acceptability and potential usefulness of the intervention. RESULTS: Thirteen training observations, 14 staff focus groups and 6 staff interviews were completed, and 438 staff (43.5 %) and 1,862 (56.3 %) students (years 8 and 9) completed questionnaires at baseline and one year later. MHFA training was considered relevant for schools, and trainees gained in knowledge, confidence in helping others, and awareness regarding their own mental health. Suggestions for reducing the length of the training and focusing on helping strategies were made. A peer support service was established in all intervention schools and was perceived to be helpful in supporting individuals in difficulty - for example through listening, and signposting to other services - and raising the profile of mental health at a whole school level. Barriers to use included lack of knowledge about the service, concerns about confidentiality and a preference for accessing support from pre-existing networks. CONCLUSIONS: The WISE intervention is feasible and acceptable to schools. Results support the development of a full-scale cluster RCT, if steps are taken to improve response rates and implement the suggested improvements to the intervention. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: ISRCTN13255300 retrospectively registered 28/09/16.

Differences in risk factors for self-harm with and without suicidal intent: findings from the ALSPAC cohort.

BACKGROUND: There is a lack of consensus about whether self-harm with suicidal intent differs in aetiology and prognosis from non-suicidal self-harm, and whether they should be considered as different diagnostic categories. METHOD: Participants were 4799 members of the Avon Longitudinal Study of Parents and Children (ALSPAC), a UK population-based birth cohort who completed a postal questionnaire on self-harm with and without suicidal intent at age 16 years. Multinomial logistic regression analyses were used to examine differences in the risk factor profiles of individuals who self-harmed with and without suicidal intent. RESULTS: Many risk factors were common to both behaviours, but associations were generally stronger in relation to suicidal self-harm. This was particularly true for mental health problems; compared to those with non-suicidal self-harm, those who had harmed with suicidal intent had an increased risk of depression (OR 3.50[95% CI 1.64, 7.43]) and anxiety disorder (OR 3.50[95% CI 1.72, 7.13]). Higher IQ and maternal education were risk factors for non-suicidal self-harm but not suicidal self-harm. Risk factors that appeared specific to suicidal self-harm included lower IQ and socioeconomic position, physical cruelty to children in the household and parental self-harm. LIMITATIONS: i) There was some loss to follow-up, ii) difficulty in measuring suicidal intent, iii) we cannot rule out the possibility of reverse causation for some exposure variables, iv) we were unable to identify the subgroup that had only ever harmed with suicidal intent. CONCLUSION: Self-harm with and without suicidal intent are overlapping behaviours but with some distinct characteristics, indicating the importance of fully exploring vulnerability factors, motivations, and intentions in adolescents who self harm.

Parental socio-economic position during childhood as a determinant of self-harm in adolescence.

PURPOSE: Socio-economic position (SEP) during childhood and parental social mobility have been associated with subsequent health outcomes in adolescence and adulthood. This study investigates whether parental SEP during childhood is associated with subsequent self-harm in adolescence. METHODS: This study uses data from a prospective birth-cohort study (the Avon Longitudinal Study of Parents and Children) which followed 14,610 births in 1991-1992 to age 16-18 years (n = 4,810). The association of parental SEP recorded pre-birth and throughout childhood with self-harm was investigated using logistic regression models, with analyses conducted separately for those reporting self-harm (a) with and (b) without suicidal intent. The impact of missing data was investigated using multiple imputation methods. RESULTS: Lower parental SEP was associated with increased risk of offspring self-harm with suicidal intent, with less consistent associations evident for self-harm without suicidal intent. Associations were somewhat stronger in relation to measures of SEP in later childhood. Depressive symptoms appeared to partially mediate the associations. Adolescents of parents reporting consistently low income levels during childhood were approximately 1.5 times more likely to engage in SH than those never to report low income. CONCLUSIONS: Lower SEP during childhood is associated with the subsequent risk of self-harm with suicidal intent in adolescence. This association is stronger in those experiencing consistently lower SEP.

The association between bankruptcy and hospital-presenting attempted suicide: a record linkage study.

The associations between admissions to an emergency department following attempted suicide and personal bankruptcy in the preceding and subsequent 2 years were evaluated. Records from a level 1 trauma center (June 1993-December 2002) in Seattle, WA, were linked with case files from the local U.S. District Bankruptcy Court (June 1991 onward). Univariable and multivariable logistic regression models were used to examine the risk of bankruptcy in (i) the 2 years after and (ii) the 2 years before a suicide attempt using a violent method, compared to patients admitted for any other reason. After adjusting for several confounders, patients who had attempted suicide were more likely than other patients to experience bankruptcy in the following 2 years (OR = 2.10, 95% CIs: 1.29, 3.42). A somewhat weaker association was seen with bankruptcy in the preceding 2 years (OR = 1.68, 95% CIs 1.06; 2.67). Attempted suicide is therefore associated with bankruptcy in the preceding and following 2 years. Changes to legislation, improved mental health counselling for those in financial difficulty, and provision of financial advice to those admitted to hospital following a suicide attempt may reduce future cases of serious self-harm and completed suicide.