Recruiting and retaining participants in three randomised controlled trials of psychological interventions conducted on acute psychiatric wards: top ten tips for success.

BACKGROUND: It is essential to conduct randomised controlled trials of psychological interventions on acute psychiatric wards to build a robust evidence base for clinical practice. AIMS: This paper aims to share strategies from three different in-patient trials that successfully recruited and retained participants, to disseminate good practice for the conduct of future trials in this challenging and complex clinical setting. METHOD: We present strategies from three in-patient trials of psychological interventions: TULIPS (Talk, Understand, Listen for Inpatient Settings), amBITION (Brief Talking Therapies on Wards) and INSITE (Inpatient Suicide Intervention and Therapy Evaluation). All studies recruited participants from acute in-patient wards, initiated therapy within the in-patient setting and followed up on participants post-discharge. RESULTS: We summarise our recommendations for good practice in the form of ten top tips for success, based on our collective experience of conducting trials on psychiatric wards. Key themes relate to the importance of relationships between the research team and clinical staff; good stakeholder involvement and getting early buy-in from the team; and adapting to the particular demands of the clinical setting. CONCLUSIONS: Sharing good practice recommendations can help reduce research waste arising from poor recruitment and/or retention in future in-patient clinical trials.

Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study.

BACKGROUND: Psychological therapy is core component of mental healthcare. However, many people with severe mental illnesses do not receive therapy, particularly in acute mental health settings. AIMS: This study identifies barriers to delivering and accessing psychological therapies in acute mental health settings, and is the first to recommend how services can increase access from the perspectives of different stakeholders (staff, patients and carers). METHOD: Sixty participants with experiences of acute mental health wards (26 staff, 22 patients and 12 carers) were interviewed about barriers to accessing therapy in in-patient settings and how therapies should be delivered to maximise access. RESULTS: Four themes were identified: (a) 'Models of care', including the function of in-patient wards, beliefs about the causes of mental health problems and the importance of strong leadership to support psychosocial interventions; (b) 'Integrated care', including the importance of psychologists being ward-based, as well as having strong links with community teams; (c) 'Acute levels of distress', including factors that aggravate or ameliorate the impact of this on engagement in therapy; and (d) 'Enhancing staff capability and motivation', which is influenced by contextual issues. CONCLUSIONS: It is possible to improve access to therapy through strong leadership (that is supportive of talking treatments), flexible delivery of therapy (that considers short admissions) and a whole-systems approach that promotes ward staff understanding of the psychosocial causes of mental illness and staff well-being. It is essential to ensure continuity between in-patient and community therapy services, and for wards to have physical space to carry out therapy.

A cluster randomised controlled trial of a ward-based intervention to improve access to psychologically-informed care and psychological therapy for mental health in-patients.

BACKGROUND: There is good evidence that psychological interventions improve patient well-being and independent living, but patients on acute mental health wards often do not have access to evidence-based psychological therapies which are strongly advised by NICE guidance for severe mental health problems. The overall aim of this programme of work is to increase patient access to psychological therapies on acute mental health inpatient wards. Stage one of the programme (which is complete) aimed to identify barriers and facilitators to delivering therapy in these settings through a large qualitative study. The key output of stage one was an intervention protocol that is designed to be delivered on acute wards to increase patient access to psychologically-informed care and therapy. Stage two of the programme aims to test the effects of the intervention on patient wellbeing and serious incidents on the ward (primary outcomes), patient social functioning and symptoms, staff burnout, ward atmosphere from staff and patient perspectives and cost effectiveness of the intervention (secondary outcomes). METHODS: The study is a single blind, pragmatic, cluster randomised controlled trial and will recruit thirty-four wards across England that will be randomised to receive the new intervention plus treatment as usual, or treatment as usual only. Primary and secondary outcomes will be assessed at baseline and 6-month and 9-month follow-ups, with serious incidents on the ward collected at an additional 3-month follow-up. DISCUSSION: The key output will be a potentially effective and cost-effective ward-based psychological intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver in inpatient settings and is acceptable to patients. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388.

A study on the feasibility of delivering a psychologically informed ward-based intervention on an acute mental health ward.

Acute mental health inpatient wards have been criticized for being nontherapeutic. The study aimed to test the feasibility of delivering a psychologically informed intervention in these settings. This single-arm study evaluated the feasibility of clinical psychologists delivering a ward-based psychological service model over a 6-month period on two acute mental health wards. Data were gathered to assess trial design parameters and the feasibility of gathering patient/staff outcome data. Psychologists were able to deliver key elements of the intervention. Baseline staff and patient participant recruitment targets were met. However, there was significant patient attrition at follow-up, with incorrect contact details on discharge being the primary reason. Implementation of a ward-based psychological intervention appears feasible when implemented flexibly. It is feasible to recruit staff and patient participants and to collect staff outcome measures over a 6-month period. However, greater efforts need to be taken to trace patient movement following discharge.

Adapting practice in mental healthcare settings during the COVID-19 pandemic and other contagions: systematic review.

BACKGROUND: During the global COVID-19 pandemic, there has been guidance concerning adaptations that physical healthcare services can implement to aid containment, but there is relatively little guidance for how mental healthcare services should adapt service provision to better support staff and patients, and minimise contagion spread. AIMS: This systematic review explores service adaptations in mental health services during the COVID-19 pandemic and other contagions. METHOD: The Allied and Complementary Medicine database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Medline, PsycINFO and Web of Science were systematically searched for published studies from database inception to April 2020. Data were extracted focusing on changes to mental health services during contagion outbreaks. Data were analysed with thematic analysis. RESULTS: Nineteen papers were included: six correspondence/point-of-view papers, five research papers, five reflection papers, two healthcare guideline documents and one government document. Analysis highlighted four main areas for mental health services to consider during contagion outbreaks: infection control measures to minimise contagion spread, including procedural and practical solutions across different mental health settings; service delivery, including service changes, operational planning and continuity of care; staff well-being (psychological and practical support); and information and communication. CONCLUSIONS: Mental health services need to consider infection control measures and implement service changes to support continuity of care, and patient and staff well-being. Services also need to ensure they are communicating important information in a clear and accessible manner with their staff and patients, regarding service delivery, contagion symptoms, government guidelines and well-being.

Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis.

BACKGROUND: The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging. OBJECTIVES: The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings. METHODS: Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model. RESULTS AND CONCLUSIONS: We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.

The Team Formulation Quality Rating Scale (TFQS): development and evaluation.

BACKGROUND: Team formulation is a core skill in mental health care, but there is currently no valid tool for assessing the quality of this process. AIM: The aim of this study was to design and evaluate a new scale, the Team Formulation Quality Scale (TFQS), which assesses both structure and content. METHODS: Experts were asked to assess the relevance and clarity of each item on the TFQS to measure its content and face validity. Two experienced Clinical Psychologists rated eight audio recorded team formulation sessions and the scores were used to assess the internal consistency and inter-rater reliability of the TFQS. RESULTS: The TFQS demonstrated good content and face validity as experts agreed all twenty-three items were relevant to measuring the quality of team formulation and rated it as understandable and comprehensive. The overall internal consistency of the TFQS was good (alpha = 0.718). The inter-rater reliability of the TFQS was consistent with individual case formulation quality measures (ICC = 0.600). CONCLUSIONS: We have developed the first scale to measure the quality of team formulation. The TFQS showed good validity and is a reliable tool that can be used in training, clinical practice and research related to team formulations.

The relationship between attachment and functioning for people with serious mental illness: a systematic review.

AIMS: Functional impairment is a hallmark feature of severe mental health problems (SMI). Attachment theory is a key psychological theory of interpersonal functioning and difficulties in attachment are common in SMI and may help explain functioning problems in SMI. This systematic review aimed to synthesise and critically appraise existing literature exploring associations between adult attachment style and functioning in SMI samples. METHOD: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines we systematically searched five databases using strings of terms relating to both attachment and social functioning. Inclusion criteria were samples diagnosed with SMI and validated measure tools. RESULTS: Ten studies met inclusion criteria. Considerable heterogeneity was found across studies in relation to construct measurement, sample size, and gender distribution. However, as predicted there was some evidence to suggest that secure attachment is associated with better functioning, and insecure attachment (specifically anxious style) is associated with impairments in functioning. CONCLUSION: Findings highlight the importance of considering attachment in relation to functional outcome when working with people with SMI, particularly when assessing, formulating, and delivering psychological interventions.

Clinical characteristics and care pathways of patients with personality disorder who died by suicide.

BACKGROUND: It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments. AIMS: To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance. METHOD: National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK. RESULTS: The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients. CONCLUSIONS: Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

A systematic review of the effects of psychosocial interventions on social functioning for middle-aged and older-aged adults with severe mental illness.

OBJECTIVES: The number of older adults with severe mental health problems such as schizophrenia is likely to double in the next 20 years. The needs of this patient group change across the life course, but difficulties with social functioning persist into older age. Poorer social functioning is associated with poorer outcomes and has been identified as a priority for intervention by patients themselves. This paper systematically reviews studies examining the effectiveness of psychosocial interventions on social functioning for people with severe mental health problems in later life. METHODS: A systematic review of peer-reviewed journal articles was conducted and databases were searched from inception to December 2017. The review was limited to psychosocial interventions, for mid to older aged adults (≥40 years of age) with severe mental illness that included a validated measure of social functioning. RESULTS: Fifteen studies (17 papers) met inclusion criteria. There was evidence to support skills training interventions that primarily focused on social skills training or integrated mental and physical health interventions. There was not sufficient evidence to recommend any other interventions. CONCLUSIONS: The results highlight the limited nature of interventions designed specifically for older people with severe mental health problems that target social functioning and the need for more robust, large-scale studies in the area. Current evidence suggests that cognitive behaviour therapy can be effective in targeting social functioning in younger age groups, but, as yet, there is insufficient evidence to recommend this intervention for an older population.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance.

BACKGROUND: Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships. OBJECTIVES: We aimed to collate and critique papers reporting on interventions targeted at improving the nurse-patient therapeutic alliance in mental health care settings. DESIGN: Systematic literature review. DATA SOURCES: The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted. REVIEW METHODS: Original journal articles in English language were included where they reported on interventions targeting the nurse-patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment. RESULTS: Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality. CONCLUSIONS: The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.