Use of a targeted, computer/web-based guided self-help psychoeducation toolkit for distressing hallucinations (MUSE) in people with an at-risk mental state for psychosis: protocol for a randomised controlled feasibility trial.

INTRODUCTION: Individuals who access at-risk mental state (ARMS) services often have unusual sensory experiences and levels of distress that lead them to seek help. The Managing Unusual Sensory Experiences (MUSE) treatment is a brief symptom targeted intervention that draws on psychological explanations to help account for unusual experiences. Practitioners use formulation and behavioural experiments to support individuals to make sense of their experiences and enhance coping strategies. The primary objective of this feasibility trial is to resolve key uncertainties before a definitive trial and inform parameters of a future fully powered trial. METHODS AND ANALYSIS: 88 participants aged 14-35 accepted into ARMS services, experiencing hallucinations/unusual sensory experiences which are considered by the patient to be a key target problem will be recruited from UK National Health Service (NHS) sites and randomised using 1:1 allocation (stratified by site, gender, and age) to either 6-8 sessions of MUSE or time-matched treatment as usual. Participants and therapists will be unblinded, research assessors are blinded. Blinded assessment will occur at baseline, 12 weeks and 20 weeks postrandomisation. Data will be reported in line with Consolidated Standards of Reporting Trials. Primary trial outcomes are feasibility outcomes, primary participant outcomes are functioning and hallucinations. Additional analysis will investigate potential psychological mechanisms and secondary mental well-being outcomes. Trial progression criteria follows signal of efficacy and uses an analytical framework with a traffic-light system to determine viability of a future trial. Subsequent analysis of the NHS England Mental Health Services Data Set 3 years postrandomisation will assess long-term transition to psychosis. ETHICS AND DISSEMINATION: This trial has received Research Ethics Committee approval (Newcastle North Tyneside 1 REC; 23/NE/0032). Participants provide written informed consent; young people provide assent with parental consent. Dissemination will be to ARMS Services, participants, public and patient forums, peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER: ISRCTN58558617.

Implications for mental health workforce strategy, professional training and supervision of more widespread adoption of the multi-professional Responsible Clinician role: Results of a qualitative inquiry.

Within mental health legislation in England and Wales the Responsible Clinician for specific patients should be the Approved Clinician with the most appropriate expertise to meet their primary assessment and treatment needs. The study aimed to explore nurse and psychologist perspectives on becoming a Responsible Clinician in the context of their limited uptake of the role and calls for an increase in advanced practice roles within mental health. It comprised a qualitative inquiry in the form of a thematic analysis of 12 semi-structured interviews. Four sub-themes emerged under the theme of 'becoming a Responsible Clinician'. They were: (i) the Responsible Clinician amongst other roles; (ii) developing in the role; (iii) working with psychiatrist colleagues; and (iv) organisational context. Responsible Clinicians were juggling the role with other senior clinical responsibilities, often without a coherent programme of ongoing educational development or organisational support structures. If mental health service provider organisations adopt this extended role more widely then role-specific support and supervision arrangements should be in place as part of a coherent workforce strategy. This is particularly important given the legal and ethical responsibilities of the Responsible Clinician.

Responsibility as professional leadership and decision making: Interviews with non-medical Responsible Clinicians.

BACKGROUND: Responsible Clinicians are professionals who are primarily accountable for the care and treatment of patients detained under the Mental Health Act, 1983 in England and Wales. The role has only been taken up by under 100 nurses and psychologists since 2007. The aim of this study was to explore the experiences of non-medical Responsible Clinicians, to inform our understanding of interprofessional dynamics and professional identity in contemporary mental healthcare. METHODS: A qualitative study comprising thematic analysis of interviews with twelve non-medical Responsible Clinicians. RESULTS: A major theme of 'Interpretations of responsibility' emerged, with two sub themes: 'Responsibility as leadership 'and 'Responsibility as decision making'. Taking on the role had implications beyond the care of specific patients. Participants saw themselves as having the power to shape their team and service whilst exercising their authority to make difficult decisions about risk and restrictions. CONCLUSIONS: More widespread adoption of the non-medical Responsible Clinician role should not be seen solely as a solution to workforce shortages or lack of opportunities for professional advancement. Consultant nurses and psychologists who take on this role are seising the opportunity to steer service developments more widely, influencing team dynamics and perceptions of accountability.

Non-medical approved clinicians: Results of a first national survey in England and Wales.

The 2007 amendments to the Mental Health Act, 1983 in England and Wales enabled non-medics to take on the role of legally 'responsible clinician' for the overall care and treatment of service users detained under the Act, where previously this was the sole domain of the psychiatrist as Responsible Medical Officer. Following state sanction as an 'Approved Clinician', certain psychologists, nurses, social workers or occupational therapists may be allocated as a Responsible Clinician for specific service users. Between 2007 and 2017 only 56 non-medics had become Approved Clinicians. This study reports on a first national survey of 39 non-medical Approved Clinicians. Descriptive statistics and thematic analysis of free text answers are presented here. The survey results show the limited uptake of the role, save for in the North Eastern region of England. Non-medical Approved Clinicians were motivated by a combination of altruistic intents (namely a belief that they could offer more psychologically-informed, recovery-oriented care) and desire for professional development in a role fitting their expertise and experience. Barriers and facilitators to wider uptake of the role appear to be: organisational support, attitudes of psychiatrist colleagues and a potentially lengthy and laborious approvals application process. The survey is a starting point to further research on the interpretation and implementation of the range of statutory roles and responsibilities under English and Welsh mental health law.

Empowerment, policy levels and service forums.

This article will examine empowerment through policy at three levels: governmental, service and 'street'. It will focus in particular on 'street level' policy, drawing on qualitative interviews and an analysis of documentation within a day centre for adults with learning difficulties. The recorded behaviour of the workers and the structure of the day centre affected service users' experience of power. This is discussed through the theoretical construction of the organization's 'service forum' that contains its 'posture', a set of formal values and beliefs owned by the organization, and the 'culture', which is the unofficial day-to-day presentation of the service. Finally the use of such an approach is considered with regards to the future analysis of services for people with learning difficulties.

Correlates of stress in carers.

BACKGROUND: Mental health services are required to take account of the needs of carers, yet little is known about how services affect carers. AIMS: This paper explores the relationship between the user's mental health problems, the services received and the impact of caring on carers. METHODS: Sixty-four carers were interviewed, measuring their experiences of care-giving, carer stress and the service user's level of impairment. A robust, composite measure of user severity was derived. RESULTS: Carers were sometimes better judges than care co-ordinators of user impairment. Their experience reflected the independently rated severity of service users' problems. When carers were aware of care plans, they felt less negative about caring. Even in above-average mental health services, carers lacked information about: care plans, medication and complaints procedures. CONCLUSIONS: This evidence can be used in allocating resources such respite care, family therapy and CBT to carers. These findings have implications for how mental health services might improve their provision for carers, for instance, involvement in care planning may help carers to cope.

Community mental healthcare in England: associations between service organisation and quality of life.

The present authors set out to explore the relationship between different forms of service organisation and quality of life (QoL) for service users. Four mental health trusts and their corresponding social services departments were recruited to exemplify: (1). high and low levels of integration between health and social services; and (2). high and low levels of targeting at users with severe mental health problems. The authors used the Lancashire Quality of Life Profile, and chose their sample size to be able to detect a difference of 0.5 in subjective satisfaction scales. Analysis of covariance was used to investigate the simultaneous impact of variables representing user characteristics, objective and subjective QoL, and service organisation. Two hundred and sixty users selected at random from the active caseloads of mental health services in the four districts were interviewed at time 1 and 232 people were interviewed 6 months later (time 2). No bias was detected in the non-respondents at time 2. The authors found few differences between districts. As in other similar studies, QoL seemed to be stable for the whole sample over time. In 6 months, general satisfaction with leisure increased and the number of people who had been in hospital fell. Negative affect score was the only variable found to be associated with subjective QoL, and no predictors of objective QoL were identified. There was some evidence of better objective outcomes for people in receipt of integrated mental health services. They socialised more, and seemed to have less difficulty accessing police and legal services. The results also suggest that interventions targeted at negative affect could have benefits for subjective QoL.

Service organisation, service use and costs of community mental health care.

BACKGROUND: Different forms of service organisation may be expected to affect costs. I is important to understand the distribution of costs amongst providers of mental health care, so that the effect of service developments on budgets can be better anticipated and planned. AIMS: This study explored the association between different forms of mental health service organisation and costs. It tested the impact on costs of services with high degrees of integration between health and social care providers, and of services targeting at people with more severe mental health problems. METHODS: 260 service users in 4 districts in the north of England were interviewed and costs identified for each person. The districts comprised examples of four types of service configuration. Use and non-use was compared by type of service, and after suitable transformations, costs were also compared between districts and between types of service. The sample was large enough to discern a difference of 50 ( 80) per week with 80% power and 5% significance. RESULTS: Costs were closely related to severity. People in targeted services had higher mean costs ( 136, SD 191 versus 92, SD 106; p=0.001). The costs of targeted services in this study were very similar to those of psychosis-only services in a London study. Integrated services were predicted to have lower inpatient costs (p=0.003), lower PCG costs (p=0.003) and lower total health and social care costs (p=0.024). Differences between use and costs of specific services were largely attributable to imprecise definitions and supply-side factors. DISCUSSION: While the sample is not representative, the a priori distinctions made in selecting the districts were reflected in service use and costs. This study suggests strongly that targeting services at people with more severe mental health problems seems likely to increase mean health and social care costs per service user. It also suggests that integration maybe associated with lower costs. Since both targeting and integration are increasingly common mental health policies, it is important to recognise that they may have opposing effects on costs.