Nigeria mental health law: Challenges and implications for mental health services.

Background: The Nigerian mental health law titled the Lunacy Act of 1958 has been under scrutiny for violating the human rights of people with mental illness. The call to reform the obsolete Lunacy Act has garnered attention from the government, as the law has been unamended for over 60 years. Aim: This study presents the challenges and implications of the new mental health law to the mental health services of Nigeria. Methods: ScienceDirect, PubMed, and Google Scholar were used to find pertinent material. The implications and difficulties facing the new mental health law examined from the literature were discussed. Recommendations were made following an exploratory search for literature on mental health legislation in Nigeria. Results: The new Law in Section 5(6) saw the introduction of mental health services in primary and secondary healthcare. It also addresses critical issues such as non-discrimination, fundamental human rights, standards of treatment, access to information, confidentiality and autonomy, and the employment rights of persons with mental health and substance abuse-related disorders. The Law failed to include mental health services in the country's health insurance system. Conclusion: There is a need for legislation to meet people's mental health needs and encourage them to seek treatments, such as regulations that protect against discrimination and harsh treatment of people with mental illness. Contribution: Nigerian mental health services would benefit from the new mental health law if the key issues raised in this review are addressed.

Evaluation of lived experience Peer Support intervention for mental health service consumers in Primary Care (PS-PC): study protocol for a stepped-wedge cluster randomised controlled trial.

BACKGROUND: The demand for mental health services in Australia is substantial and has grown beyond the capacity of the current workforce. As a result, it is currently difficult for many to access secondary healthcare providers. Within the secondary healthcare sector, however, peer workers who have lived experience of managing mental health conditions have been increasingly employed to intentionally use their journey of recovery in supporting others living with mental health conditions and their communities. Currently, the presence of peer workers in primary care has been limited, despite the potential benefits of providing supports in conjunction with GPs and secondary healthcare providers. METHODS: This stepped-wedge cluster randomised controlled trial (RCT) aims to evaluate a lived experience peer support intervention for accessing mental health care in primary care (PS-PC). Four medical practices across Australia will be randomly allocated to switch from control to intervention, until all practices are delivering the PS-PC intervention. The study will enrol 66 patients at each practice (total sample size of 264). Over a period of 3-4 months, 12 h of practical and emotional support provided by lived experience peer workers will be available to participants. Scale-based questionnaires will inform intervention efficacy in terms of mental health outcomes (e.g., self-efficacy) and other health outcomes (e.g., healthcare-related costs) over four time points. Other perspectives will be explored through scales completed by approximately 150 family members or carers (carer burden) and 16 peer workers (self-efficacy) pre- and post-intervention, and 20 medical practice staff members (attitudes toward peer workers) at the end of each study site's involvement in the intervention. Interviews (n = 60) and six focus groups held toward the end of each study site's involvement will further explore the views of participants, family members or carers, peer workers, and practice staff to better understand the efficacy and acceptability of the intervention. DISCUSSION: This mixed-methods, multi-centre, stepped-wedge controlled study will be the first to evaluate the implementation of peer workers in the primary care mental health care sector. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001189617. Registered on 17 November 2023, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386715.

A systematic review of midwives' training needs in perinatal mental health and related interventions.

Background: Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives' educational needs in perinatal mental health (PMH) or related interventions with a focus on depression or anxiety. This systematic review aims to review: 1) midwives' educational/training needs in PMH; 2) the training programs in PMH and their effectiveness in improving PMHC. Methods: We searched six electronic databases using a search strategy designed by a biomedical information specialist. Inclusion criteria were: (1) focus on midwives; (2) reporting on training needs in PMH, perinatal mental health problems or related conditions or training programs; (3) using quantitative, qualitative or mixed-methods design. We used the Mixed Methods Appraisal Tool for study quality. Results: Of 4969 articles screened, 66 papers met eligibility criteria (47 on knowledge, skills or attitudes and 19 on training programs). Study quality was low to moderate in most studies. We found that midwives' understanding of their role in PMHC (e.g. finding meaning in opening discussions about PMH; perception that screening, referral and support is part of their routine clinical duties) is determinant. Training programs had positive effects on proximal outcomes (e.g. knowledge) and contrasted effects on distal outcomes (e.g. number of referrals). Conclusions: This review generated novel insights to inform initial and continuous education curriculums on PMH (e.g. focus on midwives' understanding on their role in PMHC or content on person-centered care). Registration details: The protocol is registered on PROSPERO (CRD42021285926).

The patient's perspective on participation in a multidisciplinary team meeting: A phenomenological study.

In mental health care settings, inpatients are increasingly engaged in their care process, allowing them to participate in multidisciplinary team meetings. Research into how mental health patients (MHPs) experience participating in such meetings is, however, limited. This study aimed to explore inpatients' experiences when participating in multidisciplinary team meetings in a Belgian inpatient mental health unit. This study used a phenomenological design with data collection including semistructured interviews. Twelve individuals participated in the study. Participants were MHPs admitted to a mental health unit that works according to the model of recovery-oriented mental health practice. Findings were analysed utilising thematic analysis. Results showed that the MHPs' experiences were mainly positive but intense. Themes included: 'Feeling honoured to be invited', 'Sense of obligation', 'Feeling nervous', 'Transparency in team members' insights', 'Feeling supported by the (primary) nurse' and 'Duality about the presence of relatives'. By taking these findings into account, (mental) healthcare workers gain insight into the patient's lived experiences, allowing them to provide more person-centred care when inpatients participate in multidisciplinary team meetings. Moreover, these findings can support mental health units in implementing or optimising patient participation in multidisciplinary team meetings. Finally, other (mental health) patients can also benefit from these findings as it can help them to put feelings and thoughts into perspective when participating in a multidisciplinary team meeting during a hospital admittance.

Contacts with primary and secondary healthcare before suicide by those under the care of mental health services: case-control, whole-population-based study using person-level linked routine data in Wales, UK during 2000-2015.

BACKGROUND: People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. AIMS: To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. METHOD: This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. RESULTS: We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)). CONCLUSIONS: We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Mental Health Nurses' and Allied Health Professionals' Individual Research Capacity and Organizational Research Culture: A Comparative Study.

Introduction: Healthcare professionals have development needs related to their consumption, use, and practice of clinical research. Little is known about these issues in mental health services specifically. Objectives: A survey of healthcare staff working in an NHS Mental Health and Disability Trust in England was conducted to describe research capacity and culture compared with previously reported samples, and to examine subgroup differences. Methods: An online questionnaire was utilized. The main measure was the Research Capacity and Culture tool comprising measures of individual's perceived research skills and of team and organizational research culture. Previous studies using the same measure were systematically identified, and pooled results, weighted by sample size, were calculated. Analyses were descriptive (current sample versus previous results) and inferential (comparisons between demographic and professional groups within the current sample). Results: N = 293 people completed the survey. The median item scores were poorer than those of pooled samples from studies reporting median item scores on 39/51 (76.5%) occasions and poorer than those pooled samples of studies reporting mean item scores on 51/51 (100.0%) occasions. Individual capability for research was in the 'less than adequate' range more than in previous samples (71.4% vs. 42.9%). For team culture items, the proportions were 84.2% vs. 78.9%, while most responses about organizational culture were in the 'adequate' range (55.6% vs. 66.7%). Staff >20 years employment had poorer perceptions of team and organizational culture. Conclusion: Perceptions of individual research capacity and team and organizational culture were poor compared with previous studies, most of which were conducted in non-mental health settings. There is need for development of research capacity and culture in mental health services including opportunities to develop basic research skills through to strategic developments to promote clinical academic careers. There is considerable room for improvement in the way organizations support research and signpost opportunities.

Trends in violent offending among people with schizophrenia: A 10-year ecological study.

Violent offending committed by people with schizophrenia has been a public concern. The present study aims to examine the incidence of violent offending among people with schizophrenia and its correlations with mental health resources and economic factors. In this study, an examination of violent offending by people with schizophrenia and those identified as not criminally responsible on account of mental disorder (NCRMD) between 2010 and 2019 in China's Hunan province was undertaken. Principal component analysis (PCA) and regression analyses were used to explore the association of violent offending in people with schizophrenia and those identified as NCRMD with violent offending in the general population, mental health medical resources, and provincial GDP. Between 2010 and 2019, a total of 2,093 people with schizophrenia committed violent offending in Hunan province, including 1,374 (65.6%) cases identified as NCRMD. Over the period, the incidence of violent offending in people with schizophrenia and those identified as NCRMD has been decreasing. The incidences were positively correlated with the incidence of violent offending in the general population and negatively associated with mental health resources and provincial GDP. These findings may be valuable in helping to develop strategies for violence prevention and risk management for people with schizophrenia.

Factors contributing to readmission in patients with psychotic disorders, with a special reference to first follow-up visit in outpatient care.

BACKGROUND: Timely outpatient follow-up and readmission after discharge are common quality indicators in psychiatric care, but their association varies in previous research. We aimed to examine whether the impact of outpatient follow-up and other factors on readmission risk evolves over time in people with non-affective psychotic disorder (NAP). METHODS: The Finnish Quality of Care Register includes all people diagnosed with NAP since January 2010. Here, we followed patients with a hospital discharge between 2017 and 2021 until readmission, death, or up to 365 days. Time of the first outpatient follow-up appointment, length of stay (LOS), number of previous hospitalizations, psychosis diagnosis, substance use disorder (SUD), residential status, economic activity, gender, age, year, and region were included. Follow-up time was divided into five periods: week 1, weeks 2-4, weeks 5-13, weeks 14-25, and weeks 26-52, and each period was analyzed separately with Cox regression. RESULTS: Of the 29 858 discharged individuals, 54.1% had an outpatient follow-up within a week. A total of 10 623 (35.6%) individuals were readmitted. Short LOS increased the readmission risk in the first four weeks, whereas lack of outpatient follow-up raised the risk (adjusted HRs between 1.15 (95% CI 1.04-1.26) and 1.53 (1.37-1.71) in weeks 5-52. The number of previous hospitalizations remained a consistent risk factor throughout the follow-up, while SUD increased risk after 4 weeks and living without family after 13 weeks. CONCLUSIONS: Risk factors of readmission vary over time. These temporal patterns must be considered when developing outpatient treatment programs.

Hope in hardship: charting a new course for mental health in Afghanistan.

The long legacy of upheavals and deprivations in Afghanistan and the associated mental health impacts on its people are well documented. A systematic review undertaken by Alemi et al (2023) presents the most comprehensive synthesis to date on this topic. Drawing on their findings, this editorial examines the complex mental health and psychosocial challenges confronted by neglected vulnerable groups such as pregnant and postnatal women, LGBTQ individuals, older adults, ethnic minority groups and Afghan refugees living overseas. It explores the potential challenges in rebuilding a resilient mental health system following the mass exodus of Afghanis. It calls for a whole-of-society approach that extends beyond clinical interventions to address the broader sociocultural and economic factors influencing mental health.

Experience of naturally occurring peer support among people using psychiatric day-care in China: an interpretative phenomenology approach.

Introduction: China presently does not have an established peer support system, and the efforts of peer support workers are not acknowledged in the context of the growing global trend of community-based mental rehabilitation. This study aims to examine the first-hand experiences of persons who participate in psychiatric day-care facilities in Shanghai, China, and receive support from their peers. The goal is to gain a better understanding of how these informal peer support programs function and provide valuable knowledge for the establishment of more structured peer support programs that align with Chinese social culture. Methods: A total of 14 participants attending psychiatric day-care centres were selected for face-to-face semi-structured in-depth interviews using snowball sampling. The interviews took place between July 2021 and February 2022. The text data of the interview were acquired through transcription and then augmented using the interview scripts and additional resources. The data were analysed using interpretive phenomenological analysis until the themes reached saturation. Results: A total of three overarching themes and eight corresponding sub-themes were produced: 1. reconstructing a social network: an ordinary interpersonal connection, becoming and conducting oneself, proceeding the process of adaptation in the company of peers; 2. balance and multiple roles within the relationship: selective self-exposure, managing proximity and distance; 3. sense of meaning and sense of community: supporting others while empowering oneself, love as expanding consciousness, advocating for the notion of group identity. Discussion: This study is the initial examination of the contact and naturally occurring peer support that takes place among individuals in psychiatric day-care centres in China. The study's findings revealed that participants interact with others who have undergone similar conditions in the day-care setting, enabling them to rebuild an important social network. It is crucial to consider the possible benefits of peer support, assess the obstacles, and facilitate the personal recovery of individuals with mental disorders using the theory of recovery.

Linkage of routinely collected NHS data to evaluate liaison mental health services: challenges and lessons learned.

Background: Liaison mental health services provide mental health care to patients in acute hospital settings. Evaluation of liaison services is challenging due to their heterogeneous organisation and delivery, high case throughput and varied patient case mix. We aimed to link routinely collected National Health Service data from secondary care settings, chosen for their service characteristics, to data from primary care to evaluate hospital-based liaison mental health services in England. Methods: We planned to compare patients referred to hospital-based liaison services with comparable patients in the same hospital not referred to liaison services and comparable patients in hospitals without any liaison services. We designed and enacted a methodology to link data from: (1) Hospital Episode Statistics, a database controlled by the National Health Service Digital and (2) ResearchOne, a primary care database controlled by The Phoenix Partnership. Results: Obtaining approvals for the steps prespecified in the methodological protocol took 907 days. Enactment following approvals took 385 days. Data supplied from Hospital Episode Statistics contained 181,063 patients from 6 hospitals (mean = 30,177, standard deviation = 28,875.86) who matched the inclusion and exclusion criteria. Data supplied from ResearchOne contained 33,666 (18.6%) of these patients from the 6 hospitals (mean = 5611, standard deviation = 5206.59). Discussion: Time required for approvals and enactment was attributable to slowness of data handling processes within each data holder and to resolution of technical and organisational queries between them. Variation in number of patients for which data was supplied between databases and between hospitals was attributable to coding inconsistencies and to the limited intersection of patient populations between databases and variation in recording practices between hospitals. Conclusion: Although it is technically feasible to link primary and secondary care data, the current system is challenging, complicated, unnecessarily bureaucratic, time consuming and costly. This limits the number of studies that could be conducted with these rich data sources. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 13/58/08.

Liaison mental health services are based in acute general hospitals and provide assessment and treatment for people who have both physical and mental health problems. Our aim was to use routinely collected National Health Service data to find out whether general hospital patients referred to liaison mental health services have improved outcomes, compared with patients not referred to liaison services, and comparable patients in hospitals where there are no liaison services. The main outcomes were less time spent in hospital and fewer re-admissions to hospital following discharge. We tried to link data from routine National Health Service sources for hospital and primary care, to compare patients referred to liaison mental health services with similar people in each hospital who had not been referred, and similar people in hospitals without any liaison services at all. We planned to find out how long these people stayed in hospital, whether they were re-admitted and how much was their healthcare cost was. We experienced significant difficulties in being able to link the National Health Service data from the different organisations we approached. The whole process was extremely complex, and a delay in one part of the process resulted delays in other parts. We eventually had to abandon the research without obtaining any meaningful data, although the lessons we learnt will be useful for other researchers, so they can avoid experiencing similar problems. Routinely collected National Health Service data from primary care and secondary care can be linked using the approaches we tried, but we were unable to complete the process within the time frame of the research programme, even with time extensions. Current processes need to be streamlined and standardised with designated clear response times for the different organisations.

Understanding and Addressing the Needs of Students in Special Education Through a Trauma-Informed Resilience Curriculum.

This school program evaluation aims to highlight the mental health needs of students in special education with behavioral and emotional challenges and describe the implementation of a resilience curriculum with this population. We evaluated district mental health data from a convenience sample of 814 students in grades 5-12 special education to identify risk for mental health symptoms, violence exposure, and substance use. School social workers provided feedback on the implementation of the resilience curriculum to inform program evaluation. Students reported significant risk for traumatic stress, anxiety, and depressive symptoms, and high rates of violence exposure and substance use. School social workers described adaptations to the resilience curriculum and gave recommendations for future implementation. Students receiving special education services for behavioral and emotional challenges had high mental health need, including high rates of violence exposure, and may benefit from a trauma-informed school-based resilience curriculum adapted for their needs.

Professional characteristics, numbers, distribution and training of China's mental health workforce from 2000 to 2020: a scoping review.

Over the last 20 years, the numbers, types, distribution, and qualifications of mental health professionals in China have changed dramatically. However, there has been no systematic attempt to collect information about this transformation in the human resources available to provide mental health services-information that needs to be regularly updated to improve the country's coordination of these services. This scoping review compiles current details about China's mental health workforce and identifies critical gaps in available research and reporting. We reviewed all relevant studies and reports published between 1 January 2000 and 30 June 2021 in two English-language and four Chinese-language databases, the website of China's National Health Commission, and national and provincial health services yearbooks. In addition to summarising data from government yearbooks, we integrated relevant results from 82 peer-reviewed publications and two government reports. From 2000 to 2020, the number of psychiatrists in the country increased by 139%, and the number of psychiatric nurses increased by 340%. However, the much higher ratio of mental health professionals per 100,000 population and the better quality of training of mental health professionals in urban, eastern provinces compared to rural, western provinces has not changed. Progress has been made in standardising the training of psychiatrists, but there are no standardised training programs for psychiatric nurses, clinical psychologists, or psychiatric social workers. Future research needs to address several issues that limit the effectiveness of policies aimed at increasing the size, quality and equitable distribution of China's mental health workforce: 1) limited data available about the numbers and characteristics of professionals who provide mental health services, 2) absence of nationally standardised training programs for non-psychiatric medical professionals and non-medical personnel who provide essential monitoring and supportive care to persons with mental illnesses, and 3) failure to scientifically assess the outcomes of currently available training programs.

Patient-reported experience measures (PREMs) in outpatient psychiatry - is there an association to perceived discrimination and devaluation?

Patient-Reported Experience Measures (PREMs) are gaining significance in the field of psychiatry, with patient satisfaction being a key measure. However, it is unclear if patient satisfaction in psychiatry is influenced by variables outside the treatment setting. This brief report thus examines the possible impact of perceived discrimination and devaluation (PDD) on patient satisfaction in the psychiatric outpatient setting. Data from 1,126 individuals who were undergoing or had recently completed treatment at 15 outpatient centers of the Psychiatric University Clinic in Basel, Switzerland, was analyzed. Patient satisfaction was assessed using the Münsterlingen Patient Satisfaction Questionnaire (MüPF), and perceived stigma was measured with the Perceived Discrimination Devaluation Scale. The results revealed a positive small effect size relationship between MüPF and PDD, suggesting that patients who perceived less stigma report higher treatment satisfaction. This relationship may affect most ratings, with the total MüPF score remaining relatively robust against this potential influence. Linear regression analysis indicated that a one-unit increase in PDD score could lead to a maximum change of 1.8 points on the 7-point Likert scale for the MüPF item correlating highest with PDD and 0.4 points on the total MüPF score. These findings highlight the importance of considering perceived stigma when evaluating patient satisfaction with psychiatric outpatient treatment. Future research should investigate associations between stigma, patient satisfaction, treatment outcome, as well as other external factors that may influence patient satisfaction in psychiatric settings.

Access to Psychiatric and Education Services During Incarceration in the United States.

OBJECTIVE: Individuals with psychiatric disorders are incarcerated at disproportionately high rates and often have low educational attainment. Access to psychiatric and education services within prisons has been described as inadequate, but recent data are lacking. The authors sought to assess the association of psychiatric disorders with both educational attainment before incarceration and access to psychiatric and education services during incarceration. METHODS: Data were from the 2016 Survey of Prison Inmates, a national survey of adults incarcerated in U.S. state and federal prisons (N=24,848). Multinomial regression was used to identify associations of educational attainment before incarceration with psychiatric disorders and sociodemographic factors. Multivariable logistic regression models were used to assess associations of psychiatric disorders with access to psychiatric and education services during incarceration and with sociodemographic factors. RESULTS: Before incarceration, 57.3% of survey respondents had less than a high school diploma. Across four education and psychiatric services, only 8.4%-44.8% of respondents reported participating in these services during incarceration, despite 57.3% reporting a psychiatric or learning disorder. Psychiatric disorders were associated with lower educational attainment before incarceration and lower access to education services during incarceration. Psychiatric disorders were associated with higher odds of access to psychiatric services during incarceration. Men had lower educational attainment before incarceration and lower odds of accessing psychiatric and education services during incarceration. CONCLUSIONS: Incarcerated people had a high need for psychiatric and education services. Individuals with psychiatric disorders had lower odds of participating in education services during incarceration, highlighting the need for policies and services that increase participation.

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres.

BACKGROUND: Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce. AIMS: This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers. METHOD: Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits). RESULTS: Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (ß = -3.79, 95% CI -5.41 to -2.18; P < 0.001) and social and occupational functioning improved (ß = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5. CONCLUSIONS: Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.

Pilot evaluation of the Fiscal Mapping Process for sustainable financing of evidence-based youth mental health treatments: A comparative case study analysis.

Background: Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies. Supports are needed that can guide service agencies in accessing sustainable funding for EBTs. We conducted a pilot evaluation of the Fiscal Mapping Process, an Excel-based strategic planning tool that helps service agency leaders identify and coordinate financing strategies for their EBT programs. Method: Pilot testing of the Fiscal Mapping Process was completed with 10 youth mental health service agencies over a 12-month period, using trauma-focused cognitive-behavioral therapy or parent-child interaction therapy programs. Service agency representatives received initial training and monthly coaching in using the tool. We used case study methods to synthesize all available data (surveys, focus groups, coaching notes, document review) and contrast agency experiences to identify key findings through explanation building. Results: Key evaluation findings related to the process and outcomes of using the Fiscal Mapping Process, as well as contextual influences. Process evaluation findings helped clarify the primary use case for the tool and identified the importance-and challenges-of engaging external collaborators. Outcome evaluation findings documented the impacts of the Fiscal Mapping Process on agency-reported sustainment capacities (strategic planning, funding stability), which fully explained reported improvements in outcomes (extent and likelihood)-although these impacts were incremental. Findings on contextual factors documented the influence of environmental and organizational capacities on engagement with the tool and concerns about equitable impacts, but also the view that the process could usefully generalize to other EBTs. Conclusions: Our pilot evaluation of the Fiscal Mapping Process was promising. In future work, we plan to integrate the tool into EBT implementation initiatives and test its impact on long-term sustainment outcomes across various EBTs, while increasing attention to equity considerations.

Pilot-Testing a Tool for Planning the Sustainable Financing of Youth Mental Health Treatments that Work Plain Language Summary Youth mental health treatments that work must be consistently available to improve youth mental health in our communities, but funding for these treatments is often limited and hard to access. Youth mental health service agencies need tools that can help guide them in accessing sustainable funding for evidence-based treatments. We developed the Fiscal Mapping Process, an Excel-based strategic planning tool for planning sustainable financing of youth mental health treatment programs, and conducted a 1-year pilot-testing evaluation with 10 youth mental health service agencies. We used case study methods to compare and contrast agency experiences with using the tool, related to the process, outcomes, and contextual influences on using the Fiscal Mapping Process. Key findings included clarification of the ideal characteristics of contributors and treatment programs for using the tool; initial confirmation that the tool can improve agency-reported capacities for sustaining treatments that work and long-term sustainment outlooks, although these impacts were incremental; and documentation of the influence of environmental and organizational capacities on engagement with the tool, concerns about equitable impacts, and user views that the process could be applied to a wide range of treatment models. In summary, our pilot evaluation of the Fiscal Mapping Process showed that this tool is promising for supporting the financial sustainment of treatments that work in youth mental health services. In future research, we plan to incorporate the tool into real-world training initiatives with mental health service agencies, test its impact on long-term sustainment across a variety of treatment models, and incorporate attention to equity considerations.

Predicting patients with dementia most at risk of needing psychiatric in-patient or enhanced community care using routinely collected clinical data: retrospective multi-site cohort study.

BACKGROUND: Dementia is a common and progressive condition whose prevalence is growing worldwide. It is challenging for healthcare systems to provide continuity in clinical services for all patients from diagnosis to death. AIMS: To test whether individuals who are most likely to need enhanced care later in the disease course can be identified at the point of diagnosis, thus allowing the targeted intervention. METHOD: We used clinical information collected routinely in de-identified electronic patient records from two UK National Health Service (NHS) trusts to identify at diagnosis which individuals were at increased risk of needing enhanced care (psychiatric in-patient or intensive (crisis) community care). RESULTS: We examined the records of a total of 25 326 patients with dementia. A minority (16% in the Cambridgeshire trust and 2.4% in the London trust) needed enhanced care. Patients who needed enhanced care differed from those who did not in age, cognitive test scores and Health of the Nation Outcome Scale scores. Logistic regression discriminated risk, with an area under the receiver operating characteristic curve (AUROC) of up to 0.78 after 1 year and 0.74 after 4 years. We were able to confirm the validity of the approach in two trusts that differed widely in the populations they serve. CONCLUSIONS: It is possible to identify, at the time of diagnosis of dementia, individuals most likely to need enhanced care later in the disease course. This permits the development of targeted clinical interventions for this high-risk group.

Impact of a national audit on child and adolescent psychiatrists' prescribing practices.

BACKGROUND: A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR. METHOD: The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160). RESULTS: 102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families. DISCUSSION: Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.