Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial.

BACKGROUND: The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. METHODS: Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. FINDINGS: 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0·90 [95% CI 0·58-1·39, p=0·63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17·3 [7·6] vs 16·0 [7·1]; adjusted difference -1·28 [95% CI -2·56 to -0·01, p=0·049]). Qualitative data supported this finding. INTERPRETATION: Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. FUNDING: Medical Research Council UK and the National Institute for Health Research.

Cost-effectiveness of adherence therapy versus health education for people with schizophrenia: randomised controlled trial in four European countries.

BACKGROUND: Non-adherence to anti-psychotics is common, expensive and affects recovery. We therefore examine the cost-effectiveness of adherence therapy for people with schizophrenia by multi-centre randomised trial in Amsterdam, London, Leipzig and Verona. METHODS: Participants received 8 sessions of adherence therapy or health education. We measured lost productivity and use of health/social care, criminal justice system and informal care at baseline and one year to estimate and compare mean total costs from health/social care and societal perspectives. Outcomes were the Short Form 36 (SF-36) mental component score (MCS) and quality-adjusted life years (QALYs) gained (SF-36 and EuroQoL 5 dimension (EQ5D)). Cost-effectiveness was examined for all cost and outcome combinations using cost-effectiveness acceptability curves (CEACs). RESULTS: 409 participants were recruited. There were no cost or outcome differences between adherence therapy and health education. The probability of adherence therapy being cost-effective compared to health education was between 0.3 and 0.6 for the six cost-outcome combinations at the willingness to pay thresholds we examined. CONCLUSIONS: Adherence therapy appears equivalent to health education. It is unclear whether it would have performed differently against a treatment as usual control, whether such an intervention can impact on quality of life in the short-term, or whether it is likely to be cost-effective in some sites but not others. TRIAL REGISTRATION: Trial registration: Current Controlled Trials ISRCTN01816159.

A pilot randomised controlled trial of personalised care for depressed patients with symptomatic coronary heart disease in South London general practices: the UPBEAT-UK RCT protocol and recruitment.

BACKGROUND: Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings. METHODS: This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care.81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire. Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant's physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant's mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient's self efficacy to solve their problems.Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation. DISCUSSION: This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care. TRIAL REGISTRATION: ISRCTN21615909.

Up-beat UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients.

BACKGROUND: Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression. METHODS/DESIGN: This programme of research will consist of 4 inter-related studies. A 4 year prospective cohort study of primary care patients with coronary heart disease will be conducted to explore the relationship between coronary heart disease and depression. Within this, a nested case-control biological study will investigate genetic and blood-biomarkers as predictors of depression in this sample. Two qualitative studies, one of patients' perspectives of treatments for coronary heart disease and co-morbid depression and one of primary care professionals' views on the management of patients with coronary heart disease and depression will inform the development of an intervention for this patient group. A feasibility study for a randomised controlled trial will then be conducted. DISCUSSION: This study will provide information on the relationship between coronary heart disease and depression that will allow health services to determine the efficiency of case-finding for depression in this patient group. The results of the cohort study will also provide information on risk factors for depression. The study will provide evidence on the efficacy and feasibility of a joint patient and professional led intervention and data necessary to plan a definitive randomised controlled trial of the intervention.

A controlled trial of mental illness related stigma training for medical students.

BACKGROUND: The evidence base for mental illness related stigma interventions in health care professionals and trainees is underdeveloped. This study aimed to examine the impact of mental illness related stigma training on third year medical students' knowledge, attitudes and behaviour related to people with mental illness. METHODS: A non-randomised controlled trial was conducted with 110 third year medical students at a medical school in England to determine the effectiveness of a mental illness related stigma training package that targeted their knowledge, attitudes and behaviour. RESULTS: We detected a significant positive effect of factual content and personal testimonies training upon an improvement in knowledge, F(1, 61) = 16.3, p = 0.0002. No such difference was determined with attitudes or for behaviour. CONCLUSIONS: Knowledge, attitudes and behaviour may need to be separately targeted in stigma reduction interventions, and separately assessed. The inter-relationships between these components in mental health promotion and medical education warrant further research. The study next needs to be replicated with larger, representative samples using appropriate evaluation instruments. More intensive training for medical students may also be required.

Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey.

BACKGROUND: Many people with schizophrenia experience stigma caused by other people's knowledge, attitudes, and behaviour; this can lead to impoverishment, social marginalisation, and low quality of life. We aimed to describe the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia. METHODS: We did a cross-sectional survey in 27 countries, in centres affiliated to the INDIGO Research Network, by use of face-to-face interviews with 732 participants with schizophrenia. Discrimination was measured with the newly validated discrimination and stigma scale (DISC), which produces three subscores: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination. FINDINGS: Negative discrimination was experienced by 344 (47%) of 729 participants in making or keeping friends, by 315 (43%) of 728 from family members, by 209 (29%) of 724 in finding a job, 215 (29%) of 730 in keeping a job, and by 196 (27%) of 724 in intimate or sexual relationships. Positive experienced discrimination was rare. Anticipated discrimination affected 469 (64%) in applying for work, training, or education and 402 (55%) looking for a close relationship; 526 (72%) felt the need to conceal their diagnosis. Over a third of participants anticipated discrimination for job seeking and close personal relationships when no discrimination was experienced. INTERPRETATION: Rates of both anticipated and experienced discrimination are consistently high across countries among people with mental illness. Measures such as disability discrimination laws might, therefore, not be effective without interventions to improve self-esteem of people with mental illness.

Supported employment: randomised controlled trial.

BACKGROUND: There is evidence from North American trials that supported employment using the individual placement and support (IPS) model is effective in helping individuals with severe mental illness gain competitive employment. There have been few trials in other parts of the world. AIMS: To investigate the effectiveness and cost-effectiveness of IPS in the UK. METHOD: Individuals with severe mental illness in South London were randomised to IPS or local traditional vocational services (treatment as usual) (ISRCTN96677673). RESULTS: Two hundred and nineteen participants were randomised, and 90% assessed 1 year later. There were no significant differences between the treatment as usual and intervention groups in obtaining competitive employment (13% in the intervention group and 7% in controls; risk ratio 1.35, 95% CI 0.95-1.93, P = 0.15), nor in secondary outcomes. CONCLUSIONS: There was no evidence that IPS was of significant benefit in achieving competitive employment for individuals in South London at 1-year follow-up, which may reflect suboptimal implementation. Implementation of IPS can be challenging in the UK context where IPS is not structurally integrated with mental health services, and economic disincentives may lead to lower levels of motivation in individuals with severe mental illness and psychiatric professionals.

Alternatives to standard acute in-patient care in England: readmissions, service use and cost after discharge.

BACKGROUND: Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions. AIMS: To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services. METHOD: Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission. RESULTS: After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services. CONCLUSIONS: Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

Residential alternatives to acute in-patient care in England: satisfaction, ward atmosphere and service user experiences.

BACKGROUND: Alternatives to traditional in-patient services may be associated with a better experience of admission. AIMS: To compare patient satisfaction, ward atmosphere and perceived coercion in the two types of service, using validated measures. METHOD: The experience of 314 patients in four residential alternatives and four standard services were compared using the Client Satisfaction Questionnaire (CSQ), the Service Satisfaction Scale - Residential form (SSS-Res), the Ward Atmosphere Scale (WAS) and the Admission Experience Scale (AES). RESULTS: Compared with standard wards, service users from alternative services reported greater levels of satisfaction (mean difference CSQ 3.3, 95% CI 1.8 to 4.9; SSS-Res 11.4, 95% CI 5.0 to 17.7). On the AES, service users in alternatives perceived less coercion (mean difference -1.3, 95% CI -1.8 to -0.8) and having more ;voice' (mean difference 0.9, 95% CI 0.6 to 1.2). Greater autonomy, more support and less anger and aggression were revealed by WAS scores. Differences in CSQ and AES scores remained significant after multivariable adjustment, but SSS-Res results were attenuated, mainly by detention status. CONCLUSIONS: Community alternatives were associated with greater service user satisfaction and less negative experiences. Some but not all of these differences were explained by differences in the two populations, particularly in involuntary admission.

Public attitudes towards people with mental illness in England and Scotland, 1994-2003.

BACKGROUND: Understanding trends in public attitudes towards people with mental illness informs the assessment of ongoing severity of stigma and evaluation of anti-stigma campaigns. AIMS: To analyse trends in public attitudes towards people with mental illness in England and Scotland using Department of Health Attitudes to Mental Illness Surveys, 1994-2003. METHOD: We analysed trends in attitudes for 2000 respondents in each survey year (6000 respondents in 1996 and 1997) using quota sampling methods and the adapted Community Attitudes Toward the Mentally Ill scale. RESULTS: Comparing 2000 and 2003, there was significant deterioration for 17/25 items in England and for 4/25 items in Scotland. Neither country showed significant improvements in items between 2000 and 2003. CONCLUSIONS: Public attitudes towards people with mental illness in England and Scotland became less positive during 1994-2003, especially in 2000-2003, and to a greater extent in England. The results are consistent with early positive effects for the 'see me' anti-stigma campaign in Scotland.

Patients' views and readmissions 1 year after involuntary hospitalisation.

BACKGROUND: Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals. AIMS: To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes. METHOD: Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year. RESULTS: At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission. CONCLUSIONS: Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.

Rural-urban migration and depression in ageing family members left behind.

BACKGROUND: It has been suggested that rural-urban migration will have adverse consequences for older parents left behind. AIMS: To describe correlates of outmigration and to estimate any association between outmigration of children and depression in rural-dwelling older parents. METHOD: Population-based survey of 1147 parents aged 60 and over in rural Thailand. We randomly oversampled parents living without children. We defined an outmigrant child as living outside their parent's district, and measured depression as a continuous outcome with a Thai version of the EURO-D. RESULTS: Outmigration of all children, compared with outmigration of some or no children, was independently associated with less depression in parents. This association remained after taking account of social support, parent characteristics, health and wealth. Parents with all children outmigrated received more economic remittances and they perceived support to be as good as that of those with children close by. CONCLUSIONS: Outmigration of children was not associated with greater depression in older parents and, after taking account of a range of possible covariables, was actually associated with less parental depression. This could be explained by pre-existing advantages in families sending more migrants and by the economic benefits of migration.

In-patient and residential alternatives to standard acute psychiatric wards in England.

BACKGROUND: Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years. AIMS: Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations. METHOD: National cross-sectional survey of alternatives to standard acute in-patient care. RESULTS: We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions. CONCLUSIONS: Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Psychological wellbeing, physical impairments and rural aging in a developing country setting.

BACKGROUND: There has been very little research on wellbeing, physical impairments and disability in older people in developing countries. METHODS: A community survey of 1147 older parents, one per household, aged sixty and over in rural Thailand. We used the Burvill scale of physical impairment, the Thai Psychological Wellbeing Scale and the brief WHO Disability Assessment Schedule. We rated received and perceived social support separately from children and from others and rated support to children. We used weighted analyses to take account of the sampling design. RESULTS: Impairments due to arthritis, pain, paralysis, vision, stomach problems or breathing were all associated with lower wellbeing. After adjusting for disability, only impairment due to paralysis was independently associated with lowered wellbeing. The effect of having two or more impairments compared to none was associated with lowered wellbeing after adjusting for demographic factors and social support (adjusted difference -2.37 on the well-being scale with SD = 7.9, p < 0.001) but after adjusting for disability the coefficient fell and was non-significant. The parsimonious model for wellbeing included age, wealth, social support, disability and impairment due to paralysis (the effect of paralysis was -2.97, p = 0.001). In this Thai setting, received support from children and from others and perceived good support from and to children were all independently associated with greater wellbeing whereas actual support to children was associated with lower wellbeing. Low received support from children interacted with paralysis in being especially associated with low wellbeing. CONCLUSION: In this Thai setting, as found in western settings, most of the association between physical impairments and lower wellbeing is explained by disability. Disability is potentially mediating the association between impairment and low wellbeing. Received support may buffer the impact of some impairments on wellbeing in this setting. Giving actual support to children is associated with less wellbeing unless the support being given to children is perceived as good, perhaps reflecting parental obligation to support adult children in need. Improving community disability services for older people and optimizing received social support will be vital in rural areas in developing countries.

Course of adherence to medication and quality of life in people with schizophrenia.

This study examined the relationship over time of adherence to anti-psychotic medication and quality of life in people with schizophrenia, taking into account effects of mediating variables. Data on on adherence, quality of life, attitude towards medication, side effects, symptom severity, and level of functioning at baseline and 1-year follow-up were obtained from 373 participants in a multi-centre trial. Participants randomised to the intervention group were offered eight sessions of adherence therapy. Data were analysed via block recursive graphical modelling. Direct links between adherence and quality of life and effects across time were scarce and weak if present. However, indirect effects could be identified, i.e. adherence at baseline affected quality of life at follow-up via symptom severity and medication side effects. These findings underline associations between "traditional" clinical outcome parameters and quality of life. Adherence might have an impact on some of these clinical outcome dimensions, and this might indirectly affect quality of life across time. Overall, findings indicate that at present, there is no plausible explanatory model of adherence. This also has consequences for clinical practice since there is no compelling evidence on how to intervene effectively to improve adherence in people with schizophrenia.

Implications of long-term conditions for both mental and physical health: comparison of rheumatoid arthritis and schizophrenia.

PURPOSE: To investigate whether people with long term conditions, whatever their specific nature, need to be assessed and treated for the full range of mental, physical and social problems. Main question investigated: that rheumatoid arthritis and schizophrenia will be associated with significantly greater impairment across the subscores of the SF36 scale than in reference general population samples. Specific hypothesis tested: while rheumatoid arthritis and schizophrenia will impair both physical and mental functioning, when comparing the two groups there will be a greater difference between the physical component scores than there will be between the mental/emotional component scores of the short form health survey (SF-36). METHODS: Cross sectional comparison of SF-36 subscore profiles of cohorts of: (1) people with rheumatoid arthritis attending specialist Rheumatology outpatient clinics in five London hospitals (n = 446), and (2) people with schizophrenia treated by community psychiatric teams in four sites in Europe (n = 409). RESULTS: Both groups had greater impairments across the whole spectrum of mental and physical problems assessed by the SF-36 than age specific normative data for the general population. The results also support our hypothesis that, comparing the people with rheumatoid arthritis and schizophrenia, we did find that there is a greater discrepancy between the physical scales than there is between the mental/emotional scales of the SF-36. CONCLUSIONS: These findings show that whether the primary long-term condition is presenting as physical or as mental disorder, the practitioner should ensure that the full range of physical, mental and social problems is assessed and treated.

Methodological challenges in evaluating the effectiveness of women's crisis houses compared with psychiatric wards: findings from a pilot patient preference RCT.

There are several methodological difficulties to address when evaluating acute psychiatric services. This study explored potential methods in evaluating the effectiveness of women's crisis houses compared with psychiatric wards in a pilot patient preference randomized controlled trial. Women requiring voluntary admission to a psychiatric hospital or women's crisis house were asked to enter this pilot and different options for recruitment were explored, including different recruitment sites in the pathway to admission and methods for including women without capacity. Forty-one percent (n = 42) of women entering the study agreed to be randomized and 59% (n = 61) entered patient preference arms. Only 7% of women were recruited before admission and 1 woman without capacity entered the study, despite procedures to facilitate this. Recruitment of patients with acute psychiatric crises is therefore challenging; researchers evaluating acute services should establish a consensus on how ethically and practically to recruit patients in this setting.

Views of service users and providers on joint crisis plans: single blind randomized controlled trial.

INTRODUCTION: We report participants' and case managers' use of and views on the value of Joint Crisis Plans (JCPs), shown to reduce compulsory hospitalisation and violence. METHOD: One hundred sixty people with psychosis or bipolar disorder participated in a randomized controlled trial. Intervention group participants were interviewed on receipt of the JCP, on hospitalisation, and at 15 month follow-ups; case managers were interviewed at 15 months. RESULTS: Sixty-two of the 65 people who received a JCP (95%) were interviewed at least once. Depending on the question, 46-96% of JCP holders (N = 44) responded positively to questions concerning the value of the JCP at immediate follow up. At 15 months the proportions of positive responses to the different questions was 14-82% (N = 50). Thirty-nine to eighty-five per cent of case managers (N = 28) responded positively at 15 months. Comparing the total scores of participants who had completed both the initial and follow up questionnaires showed a shift in responses, from positive to no change, from the immediate follow up to 15 months (means 6.1 vs. 8.3, difference 2.2, 95% CI 0.8, 3.7, P = 0.003) where a higher score indicates less positive views. The two items that received highest endorsement also showed least shift over time, i.e. whether the participant would recommend the JCP to others (90% initial vs. 82% at 15 months) and whether they felt more in control of their mental health problem as a result (71% at initial vs. 56% at 15 months). Case managers at 15 months were more positive than service users, with total score means of 5 vs. 7.8 (difference -2.8, 95% CI -4.5, -1.2, P = 0.002). CONCLUSIONS: The best supported hypothesis was that participants felt more in control of their mental health problem. Together with the previously reported outcomes, this suggests JCPs empower their holders to obtain their preferred care and treatment in a crisis. Further research is needed to more clearly identify the mechanisms of action of JCPs and how their initial positive impact can be sustained.

Acquired brain injury and dementia: a comparison of carer experiences.

OBJECTIVE: As their differential needs are unknown and to inform service planning, this study (a) examined experiences of caring for adults with acquired brain injury (ABI) and (b) compared these with carers of adults with dementia. DESIGN: Cross-sectional postal survey. ABI carer experiences were compared with those of a previously studied group of dementia carers using equivalent instruments. METHODS: Family carers (n = 222) of adults with ABI: TBI (49%), strokes (26%), brain infections (18%) and other (7%) completed validated questionnaires assessing physical dependency and psychological problems of those cared for and carers' own perceived burden, quality-of-life and mental health. RESULTS: Carer burden, quality-of-life and mental health were worse for ABI carers, but were not predicted by gender, relationship, injury type, physical dependency or cognitive problems in either ABI or dementia carers. Behavioural problems of those cared for varied between the two groups and affected carers differently. Aggressive problems significantly predicted greater burden, poor quality-of-life and mental health in ABI carers, whereas passivity/low mood significantly predicted greater burden and worse quality-of-life in dementia carers. CONCLUSIONS: This study revealed different experiences of caring for younger adults with ABI vs. older adults with dementia, thereby supporting targeted development of services to sustain families affected by these conditions.

The reliability and validity of the forensic Camberwell Assessment of Need (CANFOR): a needs assessment for forensic mental health service users.

No instrument exists that measures the individual needs of forensic mental health service users (FMHSUs). The aim of this study was therefore to develop a valid and reliable individual needs assessment instrument for FMHSUs that incorporated staff and service user views and measured met and unmet needs. The Camberwell Assessment of Need was used as a template to develop CANFOR. Consensual and content validity were investigated with 50 forensic mental health professionals and 60 FMHSUs. Both were found to be satisfactory. Concurrent validity was tested using the Global Assessment of Functioning and a five-point needs scale, and again was found to be satisfactory. Reliability studies were carried out with 77 service users and 65 staff in high and medium security psychiatric services in the UK. Inter-rater reliability, rating whether a need was present or not, was high for service users (0.991) and staff (0.998). Similarly high reliability was found for unmet needs (0.985 and 0.972, respectively). Test-retest reliability was found to be moderately high for service users (0.795) and staff (0.852) when ratings were made two weeks apart. Similar levels were found for ratings of unmet needs (0.813 and 0.699, respectively). The average interview time was 23 minutes. CANFOR has good validity and reliability, and is suitable for further testing with other service user groups.