Abstract
Mental health inpatient rehabilitation services focus on people with complex psychosis who have, for example, treatment-refractory symptoms, cognitive impairment, and severe negative symptoms, which impair functioning and require lengthy admission. Engagement in activities could lead to improvement in negative symptoms and function, but few trials have been done. We aimed to investigate the effectiveness of a staff training intervention to increase patients' engagement in activities. We did a single-blind, two-arm, cluster-randomised controlled trial in 40 mental health inpatient rehabilitation units across England. Units were randomly allocated to either a manual-based staff training programme delivered by a small intervention team (intervention group, n=20) or standard care (control group, n=20). The primary outcome was patients' engagement in activities 12 months after randomisation, measured with the time use diary. With this measure, both the degree of engagement in an activity and its complexity are recorded four times a day for a week, rated on a scale of 0-4 for every period (maximum score of 112). Analysis was by intention-to-treat. Random-effects models were used to compare outcomes between study groups. Cost-effectiveness was assessed by combining service costs with the primary outcome. This study is registered with Current Controlled Trials (ISRCTN25898179). Patients' engagement in activities did not differ between study groups (coefficient 1·44, 95% CI -1·35 to 4·24). An extra £101 was needed to achieve a 1% increase in patients' engagement in activities with the study intervention. Our training intervention did not increase patients' engagement in activities after 12 months of follow-up. This failure could be attributable to inadequate implementation of the intervention, a high turnover of patients in the intervention units, competing priorities on staff time, high levels of patients' morbidity, and ceiling effects because of the high quality of standard care delivered. Further studies are needed to identify interventions that can improve outcomes for people with severe and complex psychosis. National Institute for Health Research.
Highlights
Mental health inpatient rehabilitation services in the UK focus on people with complex long-term health problems that prevent them being discharged home after an acute admission
We aimed to investigate the effectiveness of a training intervention for staff at mental health inpatient rehabilitation units to increase patients’ engagement in activities
Of the 133 services surveyed, two took part in a pilot of the study intervention and, of the remainder, 64 scored below the median value (69·6%) on the total Quality Indicator for Rehabilitative Care (QuIRC) score and were eligible for the trial. From these 64 units, 40 were randomly selected for inclusion in the REAL study. 20 units were randomly assigned to the GetREAL intervention and 20 continued with standard care
Summary
Mental health inpatient rehabilitation services in the UK focus on people with complex long-term health problems that prevent them being discharged home after an acute admission. Around 10% of new referrals to secondary mental health services need rehabilitation[7] and, at any time, only 1% of mental health inpatients occupy a rehabilitation bed. In addition to the substantial clinical challenges these individuals pose for professionals, care of patients constitutes a major resource pressure for the UK’s National Health Service (NHS) and social services, amounting to 25–50% of the total mental health budget.[8] Interventions that can reduce the need for inpatient care, even by a small reduction in length of stay, will have a large effect on resources absorbed by this population of patients
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