Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study.

BACKGROUND: There is consensus that services supporting people with complex emotional needs are part of a mental health care system in which change is needed. To date, service users' views and co-production initiatives have had little impact on the development of interventions and care. This needs to change, and our paper evidences the experiences and perspectives of a diverse range of people on how community services can best address the needs of people with complex emotional needs. METHODS: A co-produced qualitative research study. Lived experience researchers led data collection and analysis. Individual interviews were conducted with 30 people across England who had a diverse range of experiences and perspectives of using community services for complex emotional needs. Participants were asked about their experiences of using community services for their mental health, and views on how community services can best address their needs. Thematic analysis was used to analyse the data. RESULTS: Participants reported some experiences of good practice but also of experiences of severely stigmatising interventions, a lack of effective support and service fragmentation. Relational Practice was identified as the central overarching theme and describes how community services can best support people with complex emotional needs. This approach involves care delivered in a non-stigmatising, individualised and compassionate way and care that is trauma-informed. It involves care that is planned collaboratively with service users to ensure their multiple needs are addressed in a flexible, holistic and consistent way which accounts for the long-term and fluctuating nature of their needs. CONCLUSIONS: Relational practice approaches have potential to facilitate better community care for people with complex emotional needs. Research and service development are needed to examine how best to implement such approaches across the mental health service system. This work must be co-produced with people with relevant lived experience, their carers and the professionals who support them.

Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation.

BACKGROUND: Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. METHODS: Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale - Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken. DISCUSSION: This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk. TRIAL REGISTRATION: ISRCTN 32309003 . Registered on 8 April 2016.

Contact with Mental Health Services After Acute Care for Self-Harm Among Adults Released from Prison: A Prospective Data Linkage Study.

OBJECTIVE: To determine the care pathway and rate and predictors of mental health care contact within seven days of discharge from acute care following self-harm. METHOD: In a representative cohort of adults released from prisons in Queensland, Australia, we probabilistically linked person-level, statewide ambulance, emergency department, and hospital records, both prospectively and retrospectively, and community mental health service and Medicare records prospectively, to baseline survey data. We fit multivariate modified log-linked Poisson regression models to examine the association between sociodemographic, health, and criminal justice factors and mental health care contact after self-harm. RESULTS: Of 217 discharges from acute care following self-harm, 55% (n = 119) received mental health care within seven days of discharge. Mental health care contact was associated with substance use disorder (adjusted relative risk (ARR) = 0.48; 95% CI: 0.27-0.85), dual diagnosis (ARR = 0.58; 95% CI: 0.41-0.82), physical health-related functioning (ARR = 0.98; 95% CI: 0.97-0.99), being female (ARR = 1.39; 95% CI: 1.02-1.90), being identified as at risk of self-harm by correctional authorities (ARR = 1.50; 95% CI: 1.07-2.09), and prior engagement with state-funded mental health care (ARR = 1.55; 95% CI: 1.08-2.22). CONCLUSION: Our findings highlight the need to improve the integration of community mental health care for people who present to acute care following self-harm with a recent history of incarceration, particularly for men and those with substance use disorder or dual diagnosis.

Adjunctive avatar therapy for mentalization-based treatment of borderline personality disorder: a mixed-methods feasibility study.

BACKGROUND: Borderline personality disorder (BPD) is characterised by severe instability in emotions, identity, relationships and impulsive behaviour. One contributing factor to BPD is deficient mentalizing-our ability to understand the mental states of others and ourselves. Psychotherapies can be effective at reducing symptoms of BPD but effects are small. Innovative ways of enhancing existing therapies are therefore essential. OBJECTIVE: In a mixed-methods, feasibility and acceptability study, we adjuncted conventional mentalization-based treatment (MBT) for BPD with avatar software (avatar-MBT). We wanted to test whether the enhanced visual narrative afforded by the software would facilitate therapy. METHODS: We used proprietary avatar software in four group MBT sessions. We collected data on uptake (n=15), dropout (n=4) and self-report measures (n=11) of mentalization and mood and conducted qualitative interviews to assess attitudes and beliefs (n=9). FINDINGS: Thematic analysis revealed five themes on the usefulness of avatar-MBT, including facilitating perspective taking, expression, emotional distancing, the big picture and group participation. The sixth theme suggested avatar-MBT is best placed within a group setting. There was no deterioration in symptoms as monitored by self-report measures. CONCLUSIONS: Qualitative data suggest that avatar-MBT is acceptable to patients with BPD who described it as enhancing conventional MBT and expressed a wish to continue using it. However, controlled trials are required to assess efficacy. CLINICAL IMPLICATIONS: Results suggest that avatar-MBT may be a viable option to enhance existing BPD treatment. Furthermore, we provide initial evidence that it is feasible to implement a digital adjunct within a group therapy setting.

Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis.

OBJECTIVE: Suicidal behavior and self-harm are common in adolescents and are associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm and links between self-harm and suicide and risk of suicide attempt, progress in reducing suicide death rates has been elusive, with no substantive reduction in suicide death rates over the past 60 years. Extending prior reviews of the literature on treatments for suicidal behavior and repetitive self-harm in youth, this article provides a meta-analysis of randomized controlled trials (RCTs) reporting efficacy of specific pharmacological, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and nonsuicidal self-harm in adolescents. METHOD: Data sources were identified by searching the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases as of May 2014. RCTs comparing specific therapeutic interventions versus treatment as usual (TAU) or placebo in adolescents (through age 18 years) with self-harm were included. RESULTS: Nineteen RCTs including 2,176 youth were analyzed. TIs included psychological and social interventions and no pharmacological interventions. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%) (test for overall effect z = 2.31; p = .02). TIs with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). There were no independent replications of efficacy of any TI. The pooled risk difference between TIs and TAU for suicide attempts and nonsuicidal self-harm considered separately was not statistically significant. CONCLUSION: TIs to prevent self-harm appear to be effective. Independent replication of the results achieved by DBT, MBT, and CBT is a research priority.

Integrated care pathways: the way forward for continence services?

OBJECTIVES: To assess if an integrated care pathway improves the services provided for continence care. STUDY DESIGN: This was a prospective cohort study. At Worcester Royal Hospital, a UK district general hospital, an integrated care pathway was developed for the management of women presenting in primary care with continence problems. Sixty-five women referred through this pathway were compared to women referred directly to outpatients with similar problems. The outcomes compared were the time in days from referral to (1) the first medical contact, (2) diagnosis (3) physiotherapy/continence advisory review and (4) surgery or discharge. Statistical significance of the difference in outcomes was established using the Mann-Whitney U-test. RESULTS: The mean time from referral to first medical contact, urodynamic studies, physiotherapy/continence advisory team review and to surgery or discharge for the direct access patients compared to clinic patients was significantly less (p<0.05). Thirty-five percent (7/20) patients were discharged without seeing a doctor. CONCLUSION: The implementation of integrated care pathways enables a more efficient service provision for patients with incontinence problems. Thirty-five percent of women attending gynaecology outpatient department with incontinence problems could be effectively managed by urogynaecology specialist nurses.