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.

Adolescent mental well-being, religion and family activities: a cross-sectional study (Northern Ireland Schools and Wellbeing Study).

OBJECTIVES: In this study, we seek to explore the relationship between adolescent mental well-being, religion and family activities among a school-based adolescent sample from Northern Ireland. SETTING: The Northern Ireland Schools and Wellbeing Study is a cross-sectional study (2014-2016) of pupils in Northern Ireland aged 13-18 years. PARTICIPANTS: 1618 adolescents from eight schools participated in this study. OUTCOMES MEASURES: Our primary outcome measure was derived using the Warwick-Edinburgh Mental Wellbeing Scale. We used hierarchical linear regression to explore the independent effects of a range of personal/social factors, including religious affiliation, importance of religion and family activities. RESULTS: In fully adjusted models, older adolescents and females reported lower mental well-being scores-for the year-on-year increase in age ß=-0.45 (95% CI=-0.84, -0.06), and for females (compared with males) ß=-5.25 (95% CI=-6.16, -4.33). More affluent adolescents reported better mental well-being. No significant differences in mental well-being scores across religious groups was found: compared with Catholics, Protestant adolescents recorded ß=-0.83 (95% CI=-2.17, 0.51), other religious groups ß=-2.44 (95% CI=-5.49, 0.62) and atheist adolescents ß=-1.01 (95% CI=-2.60, 0.58). The importance of religion in the adolescents' lives was also tested: (compared with those for whom it was not important) those for whom it was very important had better mental well-being (ß=1.63: 95% CI=0.32, 2.95). Higher levels of family activities were associated with higher mental well-being: each unit increase in family activity produced a 1.45% increase in the mental well-being score (ß=0.78: 95% CI=0.67, 0.90). CONCLUSIONS: This study indicates that non-religious adolescents may have lower mental well-being scores when compared with their more religious peers, irrespective of religious denomination. This may relate to both a sense of lack of firm identity and perceived marginalisation. Additionally, adolescents with poor family cohesion are more vulnerable to poor mental well-being.

Occupation type, family demands and mental health: analysis of linked administrative data.

BACKGROUND: While employment generally promotes positive health and wellbeing, some jobs may be less salutogenic than others. Few studies have examined mental health across a range of broadly defined occupation types using a large population sample. AIMS: To examine the prevalence of mental health problems across a wide range of occupation types, and further examine the association of family demands, controlling for key social determinants and health-related factors. METHODS: We used linked administrative data from 2011 NI Census returns; NI Properties data; and Enhanced Prescribing Data (EPD) 2011/12. We examined self-reported mental health problems and receipt of psychotropic medication among 553,925 workers aged 25 and 59 years. RESULTS: Self-reported chronic mental ill health was more prevalent among workers in lower paid occupations, while "public- facing" occupations had the highest rates of medication. In fully adjusted models, informal caregivers were less likely to report mental health problems but more likely to be in receipt of psychotropic medication, as were lone parents. The association of family demands also varied across occupational groupings. CONCLUSION: Future development of mental health at work plans should take cognisance of occupation specific mental health risk and wider family circumstances to support workers' mental wellbeing most effectively.

Geographical Disparities and Settlement Factors and Mental Health of Refugees Living in Germany.

(1) Background: Approximately half of all refugees living in Germany experience discrimination, which may negatively affect their mental health. Moreover, German refugees have experienced hostility, especially in eastern regions. (2) Aims: We examined the effect of perceived discrimination on refugees' mental health in Germany, with a particular focus on possible regional differences of refugee mental health and perceived discrimination. (3) Method: The data of 2075 refugees who arrived in Germany between 2013 and 2016, from a large-scale survey, was analysed using binary logistic regression. The refugee health screener, 13-item version, was used to assess psychological distress. All effects were investigated for the entire sample and both sexes independently. (4) Results: A third of refugees experienced discrimination which increased the risk of psychological distress (OR = 2.25 [1.80, 2.8]). Those living in eastern Germany were more than twice as likely to report experiences of discrimination, compared to their counterparts living in western Germany (OR = 2.52 [1.98, 3.21]). Differences were noted between males and females, and religious attendance. (5) Conclusions: Perceived discrimination is a risk factor for refugee mental health, particularly female refugees in eastern Germany. An east-west regional difference may be explained by socio-structural factors, rural placement, differential historical exposure to migrant populations, and a greater presence of right-wing and populist parties in eastern Germany.

Systematic review of psychosocial needs assessment tools for caregivers of paediatric patients with dermatological conditions.

OBJECTIVE: To identify validated dermatology-specific and disease-specific psychosocial needs assessment tools for caregivers of paediatric patients with dermatological conditions. A secondary objective was to assess the adequacy of their measurement properties. DESIGN: Systematic review. DATA SOURCES: EMBASE, PsycINFO, MEDLINE (in Ovid SP), Cochrane, Cumulative Index to Nursing and Allied Health EBSCO, U Search and Web of Science were searched (2000-5 October 2021). Grey literature, bibliographies, online databases of QoL tools and several trial registers were searched (2000-5 Oct 2021). ELIGIBILITY CRITERIA: Eligible studies involved adult caregivers caring for a child (no age limit) with any form of any skin condition. Predetermined exclusion criteria, as per protocol, were applied to the search results. DATA ABSTRACTION AND SYNTHESIS: Title, abstract, full-text screening and data abstraction (standardised forms) were done independently in duplicate. Both's predefined methodological criteria assessed risk of bias. Narrative synthesis was used to present the findings. RESULTS: 187 full-text articles were examined from a total of 8979 records. Most tools were generic QoL tools, relevant to spouse/partner or based on their child's perception of the disease or assessed patients' quality of life. Following quality appraisal, 26 articles were identified, and 11 tools (1 dermatology-specific and 10 disease-specific) were included. Information outcome domains were provided for each tool (study specific, questionnaire specific, adequacy of measurement properties and risk of bias). No literature was found pertaining to the use of these tools within healthcare settings and/or as e-tools. DISCUSSION: With limited evidence supporting the quality of their methodological and measurement properties, this review will inform future dermatological Core Outcome Set development and improve evidence-based clinical decisions. Increasing demand on limited healthcare resources justifies the codevelopment of an accessible solution-focused psychosocial needs assessment e-tool to promote caregiver health outcomes. PROSPERO REGISTRATION NUMBER: PROSPERO (CRD42019159956).

Social Capital and Mental Health Among Black and Minority Ethnic Groups in the UK.

Black and minority ethnic communities are at higher risk of mental health problems. We explore differences in mental health and the influence of social capital among ethnic minority groups in Great Britain. Cross-sectional linear and logistic regression analysis of data from Wave 6 (2014-2016) of the Understanding Society databases. In unadjusted models testing the likelihood of reporting psychological distress (i) comparing against a white (British) reference population Indian, Pakistani, Bangladeshi and mixed ethnic minority groups recorded excess levels of distress; and (ii) increasing levels of social capital recorded a strong protective effect (OR = 0.94: 95% CI 0.935, 0.946). In a subsequent series of gender-specific incremental logistic models-after adjustment for sociodemographic and socioeconomic factors Pakistani (males and females) and Indian females recorded higher likelihoods of psychological distress, and the further inclusion of social capital in these models did not materially alter these results. More research on the definition, measurement and distribution of social capital as applies to ethnic minority groups in Great Britain, and how it influences mental wellbeing is needed.

Consensus statement: loneliness in older adults, the 21st century social determinant of health?

OBJECTIVE: The purpose of this consensus statement is to determine the state of the field of loneliness among older people, highlighting key issues for researchers, policymakers and those designing services and interventions. METHODS: In December 2018, an international meeting on loneliness was held in Belfast with leaders from across the USA and Europe. A summary of the conclusions reached at this event is presented following a consensus-building exercise conducted both during this event after each presentation as well as after the event through the drafting, reviewing and agreement of this statement by all authors for over 6 months. RESULTS: This meeting resulted in an agreement to produce a consensus statement on key issues including definitions of loneliness, measurement, antecedents, consequences and interventions. DISCUSSION: There has been an exponential growth in research on loneliness among older adults. However, differing measurements and definitions of loneliness mean the incidence and prevalence, associated risk factors and health consequences are often conflicting or confusing especially for those developing policy and services.

The clinical and cost-effectiveness of a Victim Improvement Package (VIP) for the reduction of chronic symptoms of depression or anxiety in older victims of common crime (the VIP trial): study protocol for a randomised controlled trial.

BACKGROUND: Older people are vulnerable to sustained high levels of psychosocial distress following a crime. A cognitive behavioural therapy (CBT)-informed psychological therapy, the Victim Improvement Package (VIP) may aid recovery. The VIP trial aims to test the clinical and cost-effectiveness of the VIP for alleviating depressive and anxiety symptoms in older victims of crime. METHODS/DESIGN: People aged 65 years or more who report being a victim of crime will be screened by Metropolitan Police Service Safer Neighbourhood Teams within a month of the crime for distress using the Patient Health Questionnaire-2 and the Generalised Anxiety Disorder-2. Those who screen positive will be signposted to their GP for assistance, and re-screened at 3 months. Participants who screen positive for depression and/or anxiety at re-screening are randomised to a CBT informed VIP added to treatment as usual (TAU) compared to TAU alone. The intervention consists of 10 individual 1-h sessions, delivered weekly by therapists from the mental health charity Mind. The primary outcome measure is the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI), used as a composite measure, assessed at 6 months after the crime (post therapy) with a 9-month post-crime follow-up. Secondary outcome measures include the EQ-5D, and a modified Client Service Receipt Inventory. A total of 226 participants will be randomised VIP:TAU with a ratio 1:1, in order to detect a standardised difference of at least 0.5 between groups, using a mixed-effects linear-regression model with 90% power and a 5% significance level (adjusting for therapist clustering and potential drop-out). A cost-effectiveness analysis will incorporate intervention costs to compare overall health care costs and quality of life years between treatment arms. An embedded study will examine the impact of past trauma and engagement in safety behaviours and distress on the main outcomes. DISCUSSION: This trial should provide data on the clinical and cost-effectiveness of a CBT-informed psychological therapy for older victims of crime with anxiety and/or depressive symptoms and should demonstrate a model of integrated cross-agency working. Our findings should provide evidence for policy-makers, commissioners and clinicians responding to the needs of older victims of crime. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number, ID: ISRCTN16929670. Registered on 3 August 2016.

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.

Patterns of long-term conditions in older age and subsequent mortality: a national study of inequalities in health.

BACKGROUND: Multiple long-term health conditions in older people are associated with increased mortality. The study aims to identify patterns of long-term health in a national ageing population using a census-based self-reported indicator of long-term health conditions. We assessed associations with subsequent mortality and socio-economic and demographic risk factors. METHODS: Using linked administrative data from the Northern Ireland Mortality Study, we assessed the presence of latent classes of morbidity in self-reported data on 11 long-term health conditions in a population aged 65 or more (N = 244 349). These classes were associated with demographic and socio-economic predictors using multi-nomial logistic regression. In a 3.75-year follow-up, all-cause and cause-specific mortality were regressed on morbidity patterns. RESULTS: Four latent classes of long-term ill-health conditions were derived, and labelled: 'low impairment'; 'pain/mobility'; 'cognitive/mental'; 'sensory impairment'. Groupings reflecting higher levels of long-term ill-health were associated with class-specific increases in all-cause and cause-specific mortality. Strongest effects were found for the 'cognitive/mental' group, which predicted all-cause mortality [hazard ratio (HR) = 2.96: 95% confidence interval (CI) = 2.83, 3.10) as well as some cause-specific mortality (i.e. dementia-related death: HR = 10.78: 95% CI = 9.39, 12.15). Class membership was predicted by a range of socio-demographic factors. Lower socio-economic status was associated with poorer health. CONCLUSION: Results indicate that long-term ill-health clusters in specific patterns, which are both predicted by socio-demographic factors and are themselves predictive of mortality in the elderly. The syndromic nature of long-term ill-health and functioning in ageing populations has implications for healthcare planning and public health policy in older populations.

Accuracy of psychometric tools in the assessment of personality in adolescents and adults requesting gender-affirming treatments: A systematic review.

BACKGROUND: The assessment and screening for personality disorders in individuals requesting gender affirming treatments may be an important aspect of predicting medical and surgical outcomes for this population, but there is no consensus on how best to do so. AIMS: To review the diagnostic accuracy of psychometric tools used for the assessment of personality disorders in those requesting gender affirming treatments. METHOD: A systematic review: Prospero CRD42017078783 [1]. RESULTS: Many studies have focussed on the assessment of personality disorders in this population, but since 1979, only two have used an index and reference test. CONCLUSION: There are no agreed reference standards for this population and psychometric tools continue to be scored on reference data from the cisgender (not transgender) population. We need robust evidence on this issue, as individuals may be denied access to gender affirming treatments based on psychometric tools without established reliability in this population.

Symptom profiles of late-life anxiety and depression: The influence of migration, religion and loneliness.

OBJECTIVE: To examine (1) clinically relevant anxiety with comorbid depression in an older population, and the presentation of subthreshold symptoms; (2) to assess anxiety and levels of comorbid depression associated with migration, religion, loneliness and long-term illness. METHODS: Analysis of Wave 1 of The Irish Longitudinal Study on Ageing (TILDA) (2009-2011). Latent class analysis (LCA) was used to define indicative diagnoses of anxiety and depression. We then assessed associations between sociodemographic and socioeconomic factors, past migration, religious practice, social network, loneliness and long-term illness. RESULTS: For those with clinically relevant anxiety, LCA derived three classes of self-reported depression: low, subthreshold and high. Approximately 19% were comorbid, and a further 37% reported subthreshold depression. Compared to those with low/no symptoms of depression, those classed as comorbid were more likely to be male, had lower education levels, had spent more time abroad, lower religious attendance, a limited social network, were lonelier and had a long-term life-limiting illness. Those with subthreshold levels of depression reported a more restricted social network and more moderate levels of loneliness. CONCLUSION: Findings support the actuality of comorbidity of both disorders. Consequently, government health strategy on detecting and managing social engagement, loneliness, and psychological disorders in older people may require a more granulated approach.

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.

Quality of life, autonomy, satisfaction, and costs associated with mental health supported accommodation services in England: a national survey.

BACKGROUND: Little research has been done into the effectiveness of mental health supported accommodation services. We did a national survey to investigate provision and costs of services and assess service user quality of life and outcomes across England. METHODS: We randomly sampled three types of services from 14 nationally representative regions-residential care, supported housing, and floating outreach-and recruited up to ten service users per service. Service quality and costs and service users' quality of life, autonomy, and satisfaction with care were assessed in a standardised manner with validated tools and compared by multilevel modelling. FINDINGS: 619 service users were recruited from 22 residential care, 35 supported housing, and 30 floating outreach services. Those in residential care and supported housing had more severe mental health problems than those in floating outreach. 348 (57%) were assessed as being at risk of severe self-neglect and 229 (37%) as being vulnerable to exploitation in the previous 2 years. Residential care was most expensive but provided for people with the greatest needs. The mean annual budget was £466 687 for residential care (range £276 000-777 920), compared with £365 452 for supported housing (£174 877-818 000), and £172 114 for floating outreach (£17 126-491 692). Quality of care was best in supported housing. People in supported housing and floating outreach were more socially included but experienced more crime than those in residential care. After adjustment for service quality and service user sociodemographic and clinical factors, quality of life was similar for service users in residential care and supported housing (mean difference -0·138, 95% CI -0·402 to 0·126, p=0·306) and lower for those in floating outreach than in residential care (-0·424, -0·734 to -0·114, p=0·007). However, autonomy was greater for those in supported housing than for those in residential care (0·145, 0·010 to 0·279, p=0.035). Satisfaction with care was similar across services. INTERPRETATION: Supported housing might be cost-effective, but the benefits need to be weighed against the risks associated with increased autonomy. FUNDING: National Institute for Health Research.

An ethnographic study of strategies to support discussions with family members on end-of-life care for people with advanced dementia in nursing homes.

BACKGROUND: Most people with advanced dementia die in nursing homes where families may have to make decisions as death approaches. Discussions about end-of-life care between families and nursing home staff are uncommon, despite a range of potential benefits. In this study we aimed to examine practices relating to end-of-life discussions with family members of people with advanced dementia residing in nursing homes and to explore strategies for improving practice. METHODS: An ethnographic study in two nursing homes where the Compassion Intervention was delivered. The Compassion Intervention provides a model of end-of-life care engaging an Interdisciplinary Care Leader to promote integrated care, educate staff, support holistic assessments and discuss end of life with families. We used a framework approach, undertaking a thematic analysis of fieldwork notes and observations recorded in a reflective diary kept by the Interdisciplinary Care Leader, and data from in-depth interviews with 23 informants: family members, GPs, nursing home staff, and external healthcare professionals. RESULTS: Four major themes described strategies for improving practice: (i) educating families and staff about dementia progression and end-of-life care; (ii) appreciating the greater value of in-depth end-of-life discussions compared with simple documentation of care preferences; (iii) providing time and space for sensitive discussions; and (iv) having an independent healthcare professional or team with responsibility for end-of-life discussions. CONCLUSIONS: The Interdisciplinary Care Leader role offers a promising method for supporting and improving end-of-life care discussions between families of people with advanced dementia and nursing home staff. These strategies warrant further evaluation in nursing home settings.

Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England.

BACKGROUND: Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10-20 % of all those with psychosis, they absorb 25-50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome. METHOD: Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care. RESULTS: Across England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients' social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00-1.08), and patients' activity (OR 1.03, 95 % CI 1.01-1.05) and social skills (OR 1.13, 95 % CI 1.04-1.24) at recruitment. CONCLUSION: Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients' social skills and activities may further enhance the effectiveness of these services.

Development and psychometric properties of the client's assessment of treatment scale for supported accommodation (CAT-SA).

BACKGROUND: Patient-Reported Outcome Measures (PROMs) are important for evaluating mental health services. Yet, no specific PROM exists for the large and diverse mental health supported accommodation sector. We aimed to produce and validate a PROM specifically for supported accommodation services, by adapting the Client's Assessment of Treatment Scale (CAT) and assessing its psychometric properties in a large sample. METHODS: Focus groups with service users in the three main types of mental health supported accommodation services in the United Kingdom (residential care, supported housing and floating outreach) were conducted to adapt the contents of the original CAT items and assess the acceptability of the modified scale (CAT-SA). The CAT-SA was then administered in a survey to service users across England. Internal consistency was assessed using Cronbach's alpha. Convergent validity was tested through correlations with subjective quality of life and satisfaction with accommodation, as measured by the Manchester Short Assessment of Quality of Life (MANSA). RESULTS: All seven original items of the CAT were regarded as relevant to appraisals of mental health supported accommodation services, with only slight modifications to the wording required. In the survey, data were obtained from 618 clients. The internal consistency of the CAT-SA items was 0.89. Mean CAT-SA scores were correlated with the specific accommodation item on the MANSA (r s = 0.37, p ˂ .001). CONCLUSIONS: The content of the CAT-SA has relevance to service users living in mental health supported accommodation. The findings from our large survey show that the CAT-SA is acceptable across different types of supported accommodation and suggest good psychometric properties. The CAT-SA appears a valid and easy to use PROM for service users in mental health supported accommodation services.

Locating the Social Origins of Mental Illness: The Explanatory Models of Mental Illness Among Clergy from Different Ethnic and Faith Backgrounds.

Clergy have historically provided 'healing' through various spiritual and medical modalities and even in modern, developed welfare economies they may still be an important help-seeking resource. Partnerships between religion and psychiatry are regularly advocated, but there is scant research on clergy explanatory models of illness. This paper aimed to explore their relationship with psychiatry and to examine how clergy in various faith groups conceptualised mental health problems. In this qualitative study using in-depth interviews, these issues were explored with 32 practising clergy in the UK from a range of different Christian, Muslim and Jewish faith organisations and ethnic backgrounds. This paper presents findings related to clergy explanatory models of mental illness and, in particular, how the social factors involved in causation are tinged with spiritual influences and implications, and how the meanings of mental distress assume a social and moral significance in distinctive localised matters.

Does social disadvantage over the life-course account for alcohol and tobacco use in Irish people? Birth cohort study.

AIMS: Few studies have examined how the settlement experiences of migrant parents might impact on the downstream adult health of second-generation minority ethnic children. We used prospective data to establish if childhood adversity relating to the settlement experiences of Irish-born parents might account for downstream adverse health-related behaviours in second-generation Irish respondents in adulthood. DESIGN, SETTING AND PARTICIPANTS: Cohort data from the National Child Development Study, comprising 17 000 births from a single week in 1958, from Britain, were analysed. Respondents were followed to mid-life. Dependent variables were alcohol and tobacco use. The contribution of life-course experiences in accounting for health-related behaviours was examined. FINDINGS: Relative to the rest of the cohort, the prevalence of harmful/hazardous alcohol use was elevated in early adulthood for second-generation men and women, although it reduced by age 42. Second-generation Irish men were more likely to report binge alcohol use (odds ratio 1.45; 95% confidence interval 0.99, 2.11; P = 0.05), and second-generation Irish women were more likely to smoke (odds ratio 1.67; 95% confidence interval 1.23, 2.23; P = 0.001), at mid-life. Childhood disadvantage partially mediated associations between second-generation Irish status and mid-life alcohol and tobacco use, although these were modest for associations with smoking in Irish women. CONCLUSIONS: The findings suggest mechanisms for the intergenerational 'transmission' of health disadvantage in migrant groups, across generations. More attention needs to focus on the public health legacy of inequalities transferring from one migrant generation to the next.

Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users' engagement in activities.

BACKGROUND: This study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this. METHODS/DESIGN: This study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users' engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a "hands-on", manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care. DISCUSSION: The study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).