Preventing Suicide in Lesbian, Gay, Bisexual, and Transgender Prisoners: A Critique of U.K. Policy.

Suicide is a global problem in prisons. As in society generally, gay men in prison have a higher risk of attempting suicide compared with their heterosexual peers. The Howard League for Penal Reform Sex in Prison Commission 2015 reveals a pervasive culture of consensual and coercive sexual relations, with gay men more likely to be targeted for unsolicited sex. Research shows an inadequate institutional response to such abuse. Victims of sexual assault in prison have high rates of psychological problems, which can lead to self-harm and suicide. The Assessment, Care in Custody and Teamwork procedure to assess and manage risk of suicide in prisoners, however, makes no reference to the needs of the lesbian, gay, bisexual, and transgender prison population, despite national policy and best practice guidance that advocates an individualized approach to suicide risk with due consideration of vulnerable group status. This article argues that the Assessment, Care in Custody and Teamwork procedure should be tuned to the requirements of the Equality Act 2010 to ensure that lesbian, gay, bisexual, and transgender prisoners are not exposed to the double jeopardy of sexual assault and related suicidal tendencies.

Vantage point - A private matter.

IMAGINE THAT you have been struggling with depression and your doctor has referred you for cognitive behaviour therapy (CBT). Such treatment is provided on the NHS through the Improving Access to Psychological Therapies (IAPT) programme. But there is a catch; you have been placed on a three-month waiting list.

Community question.

THE BED manager scanned the whiteboard in the busy office of an acute psychiatric ward. 'What about this man, WL?' she asked. 'He's been in for nearly two weeks. Can he go on weekend leave?' The nurse in charge was sceptical, but an urgent admission was imminent, and there was no room. So WL was informed that he was ready for a trial period at home, and his bed was swiftly changed for the new arrival. Such is life in the inner-city psychiatric ward, where demand relentlessly exceeds supply.

Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial.

BACKGROUND: Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes. AIMS: To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia. METHOD: A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0-13 weeks and 0-39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods. RESULTS: There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively. CONCLUSIONS: In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.

Contribution of research networks to a clinical trial of antidepressants in people with dementia.

BACKGROUND: The Mental Health Research Network and Dementia and Neurodegenerative Diseases Research Network were established in the UK to increase research capacity and activity; the former in mental health generally, and the latter specifically in neurodegenerative disorders including dementia. Little evidence exists on the impact of these networks on research in mental health of older people. AIMS: To examine research network support to a multi-centre randomised controlled trial of antidepressants in people with depression superimposed on dementia. Method Qualitative questionnaires were completed by principal investigators, trial-funded research workers and clinical study officers (CSOs) of the research networks. RESULTS: Research network contribution was much valued by principal investigators and the nine research teams. CSOs boosted the recruitment campaign in a challenging environment and enhanced assessment processes. Some problems with consistency and staff turnover were raised. CONCLUSION: Research network input can make an appreciable difference to the process and outcome of a multi-centre clinical trial.

Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care.

AIM: This paper presents a discussion of the role of nursing models and theory in the modern clinical environment. BACKGROUND: Models of nursing have had limited success in bridging the gap between theory and practice. DATA SOURCES: Literature on nursing models and theory since the 1950s, from health and social care databases. DISCUSSION: Arguments against nursing theory are challenged. In the current context of multidisciplinary services and the doctrine of evidence-based practice, a unique theoretical standpoint comprising the art and science of nursing is more relevant than ever. IMPLICATIONS FOR NURSING: A theoretical framework should reflect the eclectic, pragmatic practice of nursing. CONCLUSION: Nurse educators and practitioners should embrace theory-based practice as well as evidence-based practice.

Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial.

BACKGROUND: Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo. METHODS: We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38. FINDINGS: Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39. INTERPRETATION: Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered. FUNDING: UK National Institute of Health Research HTA Programme.

Modernizing mental health services for older people: a case study.

BACKGROUND: This paper describes an evaluation of a redevelopment program in a mental health service for older people, stimulated by U.K. Department of Health policy. IQCOL (Improving Quality of Care for Older People in Lambeth) was a two-year program to modernize and expand an inner-city service, with objectives to improve access, embed new functions, and tune the service towards the needs of the local community. The program evaluation aimed to contribute to knowledge on service planning and methodology for evaluating complex interventions. METHODS: The study evaluated the progress and outcomes of this multifaceted program. The realist model of evaluation was followed, with a dual emphasis on utility and generalizability. With an iterative approach, the pragmatic, longitudinal design comprised a combination of qualitative and quantitative methods to explain the process of change and to measure achievement of objectives. RESULTS: A high level of participation in evaluation activities was achieved. The workforce generally responded well to the program. However, progress in one team was hindered by understaffing and resistance to change, emphasizing that while localized provision may be desirable, team viability requires adequate resources and professional support. Improved access was indicated by a 13% increase of referrals. Data suggested earlier referral of dementia cases. Carer support was implemented, but assertive outreach was impeded by professional boundary issues. Ethnicity data showed that the service was responding to demographic trends. Positive views towards the program were associated with team resources and recent professional training. CONCLUSIONS: This case study demonstrates how whole system change can be achieved if sufficient attention is given to the needs of staff implementing the program. The evaluation emphasizes the importance of context in producing generalizable evidence on service development, and contributes useful methodological insights.

The challenge of evaluating mental health services for older people.

BACKGROUND: Despite a consensus on the need to expand and improve mental health care for older people, evidence on models of service development is limited. OBJECTIVE: Referring to two case studies, this paper considers how evaluation of service innovations can inform policy and practice. CONCLUSIONS: Evaluation should entail a dual concern with measurement and meaning in judging the value of an intervention.

An extra pair of hands? A case study of the introduction of support workers in community mental health teams for older adults.

BACKGROUND: Despite the expanding deployment of support workers in mental health services, little evidence exists on what managers and professional practitioners should expect of such staff in community settings. AIMS: This case study evaluated the introduction of support workers in community mental health teams for older adults. METHOD: A multiple method design engaged support workers and professional colleagues in individual interviews, a focus group and a work satisfaction survey. RESULTS: While the new resource boosted service provision, disparity between the intended role and the assumptions of professional practitioners caused confusion and dissatisfaction. CONCLUSIONS: The study highlights the need for managers to ensure role clarity when non-professional workers are introduced into multidisciplinary community teams. IMPLICATIONS FOR NURSING MANAGEMENT: Promoting diversity of skills in the mental health workforce is a progressive move in tuning services to the heterogenous needs of clients in the community. However, introducing unqualified workers into multi-disciplinary teams necessitates clear guidance to prevent their activity being confined within existing professional models. Support workers offer much potential in innovative service delivery.