Mental Health Services In England Research Articles

Remotely Delivered Video Interaction Guidance for Families of Children With an Intellectual Disability Referred to Specialist Mental Health Services: Protocol for a Feasibility Randomized Controlled Trial.

Children with an intellectual disability (ID) are 3-4 times more likely to present with behaviors that challenge and mental health problems than typically developing children. Parenting and the quality of parent-child relationships are risk factors for these families. The COVID-19 pandemic further exacerbated difficulties, leading to an increase in child mental health problems and behaviors that challenge, a deterioration in parental mental health, and further strain on family relationships. Remote family interventions could be an effective solution for both families and specialist mental health services. Video interaction guidance (VIG) has shown promise for improving child mental health. However, it is unclear whether it is widely acceptable to families and feasible to implement across specialist child mental health services. This randomized controlled trial aims to evaluate the feasibility of delivering VIG as a remote intervention for parents of children aged 6-12 years with ID who have been referred to specialist mental health services. The study will be undertaken across 5-7 National Health Service specialist mental health services in England, involving 50 participants randomly allocated on a 1:1 basis to either the intervention group (receiving remote VIG) or the treatment-as-usual (TAU) group. The intervention group will engage in 3-5 cycles of VIG delivered remotely over 12 weeks. The primary feasibility outcomes include the recruitment rate, retention at 6-month follow-up, and VIG cycle completion rate. The secondary outcomes will assess the acceptability of VIG and the feasibility of remote implementation, including fidelity to the intervention protocol. Data will be gathered through online surveys and telephone interviews at baseline, 3 months, and 6 months. Feasibility outcomes will be summarized using descriptive statistics, while thematic analysis will be applied to qualitative data from semistructured interviews with participants, VIG practitioners, and service managers. An embedded process evaluation will explore barriers and facilitators to engagement with VIG, and a parallel health economics evaluation will assess the feasibility of capturing service use data and intervention costs. The trial was open to recruitment between December 2022 and March 2024. The first results should be available in 2025. The study is the first randomized evaluation of VIG as offered to parents of children with ID who have been referred to specialist mental health settings. The outcomes from this feasibility trial will inform the decision to proceed with a definitive trial, using a traffic light system to evaluate recruitment, retention, and VIG completion rates alongside qualitative insights and economic evaluations. ISRCTN Registry ISRCTN13171328; http://www.isrctn.com/ISRCTN13171328. DERR1-10.2196/54619.

A Qualitative Service Evaluation of the Introduction of Single Session Therapy for Families in a Child and Adolescent Mental Health Service in England, United Kingdom.

This service evaluation details the process of introducing Single Session Therapy (SST) with families to a Child and Adolescent Mental Health Service in the United Kingdom. SST is a model of short-term psychotherapy intervention which can be applied to family contexts to provide timely mental health support. This service evaluation had two objectives: (1) Review the existing evidence base and literature for SST. (2) Evaluate the implementation of a new SST treatment pathway in CAMHS, including patient experiences and satisfaction with the service. SQUIRE Guidelines are used to report on this new knowledge of healthcare. This evaluation used qualitative methods to evaluate the impact of the new service. The team also used existing frameworks within the Trust, namely discharge data, which is collected routinely as part of service evaluation. This evaluation suggests positive support for this model, and that many families appreciate and value the opportunity to build on strengths and work toward their goals as families. This project outcome appears to support some of Talmon's (1990) findings that the most commonly attended number of sessions is one, and that of those who attended only one session, many perceived the session as useful. Waiting times for our service are extremely long. The pace and structure around goals and solutions could feel both galvanising, as some reported, but others felt it was an insufficient response to the severity of their difficulties. More high-quality research is needed before judgments can be made around the cost-effectiveness or efficacy of SST over existing approaches in the United Kingdom. While implementing SST should not be used to justify reduction in existing interventions, it offers a positive additional service for young people experiencing mental health difficulties and their families.

Suicide-related internet use of mental health patients: what clinicians know.

Suicide-related internet use (SRIU), defined as internet use related to one's own feelings of suicide, can be both a risk and protective factor, especially for isolated individuals. Despite its influence on suicidality, clinicians face challenges in assessing SRIU because of the private nature of internet usage. Current recommendations on enquiring about SRIU in a clinical setting concern mostly young people. To address the gap in understanding SRIU among patients of all ages, this study aims to explore mental health clinicians' experiences, attitudes and beliefs regarding enquiring about SRIU, as well as the risks and benefits it presents in the assessment and management of patients. Finally, the study aims to establish the role SRIU potentially plays in the assessment and management of patients. Twelve clinicians practising at secondary mental health services in England participated in interviews. Thematic analyses were used for data interpretation. Clinicians who participated in interviews rarely initiate discussions on SRIU with their patients despite considering this an important factor in suicidality. Age of both patients and clinicians has the potential to influence enquiry into SRIU. Clinicians recognise the potential benefits of patients finding supportive online communities but also express concerns about harmful and low-quality online content related to suicide. Integrating SRIU enquiry into standard clinical practice, regardless of the patient's age, is an important step towards comprehensive patient care. Broader training for clinicians on enquiring about online behaviours is essential to mitigate potential risks and harness the benefits of SRIU in mental health patients.

Adjusting the risk-adjustment: Accounting for variation between organisations in the responsiveness of their expenditure to need

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the ‘responsiveness of expenditure to need’ and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations.

Clinical effectiveness and cost-effectiveness of Structured Psychological Support for people with probable personality disorder in mental health services in England: study protocol for a randomised controlled trial

IntroductionEvidence-based psychological treatments for people with personality disorder usually involve attending group-based sessions over many months. Low-intensity psychological interventions of less than 6 months duration have been developed, but their...

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

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. 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. 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). 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. 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. 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.

Varying coefficient panel data models and methods under correlated error components: Application to disparities in mental health services in England

The contribution of this paper is twofold. Firstly, it introduces novel regression models that combine two important areas of the methodological development in panel data analysis, namely a varying coefficient specification and spatial error dependence. The former allows relatively flexible nonlinear interactions; the latter enables spatial correlations of the disturbance and thus differ significantly from the other random effect models in the literature. To estimate the model, a new estimation procedure is established that can be viewed as a generalization of the quasi-maximum likelihood method for a spatial panel data model to the well-known conditional local likelihood procedure. Novel inference methods, particularly variable selection and hypothesis testing of the parameter constancy, are introduced and are shown to be effective under the complex spatial error dependence. Equally importantly, this paper makes a substantial contribution to the understanding of financing and expenditure for health and social care. In particular, we empirically analyze and explain the effects of political ideologies on the local fiscal policy in England, especially the expenditure on mental health services.

How can we improve mental health crisis services for young people? A survey of mental health crisis professionals across Greater Manchester

BackgroundHealthcare providers have been under pressure to improve the provision of crisis mental health services in England. Through the process of devolution, Greater Manchester has created the Crisis Care Pathway to meet the growing demands on mental health crisis service provision for young people in the city region. At the end of the first funding cycle, this research evaluated the pathway with a focus on potential future improvements.MethodsAn online survey, including a mixture of quantitative, Likert scale items and qualitative, open-ended questions, was completed by 60 professionals working within crisis mental health services for young people in Greater Manchester.ResultsAnalysis of the quantitative data identified 6 clear areas for improvement from the evaluative indicators: delivering support at a time that works for young people; delivering the right amount of help for the right length of time; providing services which are quickly available; services and agencies working together effectively; movement between services; fully integrated services. A further 3 super-ordinate themes were developed through thematic analysis of the qualitative data that indicate areas in need of improvement: The challenge of navigation, issues of accessibility into and between services, and how to improve integration.ConclusionsThis research found 7 clear actions to enhance the provision of crisis mental health services for young people in Greater Manchester, which may be transferable to other mental health crisis service contexts.

Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomised controlled trial

Anxiety problems are common in children, yet few affected children access evidence-based treatment. Digitally augmented psychological therapies bring potential to increase availability of effective help for children with mental health problems. This study aimed to establish whether therapist-supported, digitally augmented, parent-led cognitive behavioural therapy (CBT) could increase the efficiency of treatment without compromising clinical effectiveness and acceptability. We conducted a pragmatic, unblinded, two-arm, multisite, randomised controlled non-inferiority trial to evaluate the clinical effectiveness and cost-effectiveness of therapist-supported, parent-led CBT using the Online Support and Intervention (OSI) for child anxiety platform compared with treatment as usual for child (aged 5-12 years) anxiety problems in 34 Child and Adolescent Mental Health Services in England and Northern Ireland. We examined acceptability of OSI plus therapist support via qualitative interviews. Participants were randomly assigned (1:1) to OSI plus therapist support or treatment as usual, minimised by child age, gender, service type, and baseline child anxiety interference. Outcomes were assessed at week 14 and week 26 after randomisation. The primary clinical outcome was parent-reported interference caused by child anxiety at week 26 assessment, using the Child Anxiety Impact Scale-parent report (CAIS-P). The primary measure of health economic effect was quality-adjusted life-years (QALYs). Outcome analyses were conducted blind in the intention-to-treat (ITT) population with a standardised non-inferiority margin of 0·33 for clinical analyses. The trial was registered with ISRCTN, 12890382. Between Dec 5, 2020, and Aug 3, 2022, 706 families (706 children and their parents or carers) were referred to the study information. 444 families were enrolled. Parents reported 255 (58%) child participants' gender to be female, 184 (41%) male, three (<1%) other, and one (<1%) preferred not to report their child's gender. 400 (90%) children were White and the mean age was 9·20 years (SD 1·79). 85% of families for whom clinicians provided information in the treatment as usual group received CBT. OSI plus therapist support was non-inferior for parent-reported anxiety interference on the CAIS-P (SMD 0·01, 95% CI -0·15 to 0·17; p<0·0001) and all secondary outcomes. The mean difference in QALYs across trial arms approximated to zero, and OSI plus therapist support was associated with lower costs than treatment as usual. OSI plus therapist support was likely to be cost effective under certain scenarios, but uncertainty was high. OSI plus therapist support acceptability was good. No serious adverse events were reported. Digitally augmented intervention brought promising savings without compromising outcomes and as such presents a valuable tool for increasing access to psychological therapies and meeting the demand for treatment of child anxiety problems. Department for Health and Social Care and United Kingdom Research and Innovation Research Grant, National Institute for Health and Care (NIHR) Research Policy Research Programme, Oxford and Thames Valley NIHR Applied Research Collaboration, Oxford Health NIHR Biomedical Research Centre.

Leave for informally admitted patients: a review of written guidance produced by mental health services in England and Wales

PurposeThe purpose of this paper is to report on the use and content of written guidance produced by mental health services in England and Wales describing hospital leave for informally admitted patients.Design/methodology/approachGuidance on leave was requested from National Health Service (NHS) mental health trusts in England and health boards in Wales (n = 61) using a Freedom of Information submission. Data were analysed using content analysis.FindingsIn total, 32 organisations had a leave policy for informal patients. Policies varied considerably in content and quality. The content of policies was not supported by research evidence. Organisations appeared to have developed their policies by either adapting or copying the guidance on section 17 leave outlined in the Mental Health Act Codes of Practice for England and Wales (Department of Health, 2016; Welsh Government, 2016). Definitions of important terms, for example, leave and hospital premises, were either absent or poorly defined. Finally, some organisations appeared to be operating pseudo-legal coercive contracts to prevent informal patients from leaving hospital wards.Research limitations/implicationsResearch should be undertaken to explore the impact of local policies on the informal patient’s right to life and liberty.Practical implicationsAll NHS organisations need to develop an evidence-based policy to facilitate the informal patient’s right to take leave. A set of national standards that organisations are required to comply with would help to standardise the content of leave policies.Originality/valueTo the best of the author’s knowledge, this is the first study to examine the use and content of local policies describing how informal patients can take leave from hospital.

Mental health interventions for children and young people with long-term health conditions in Children and Young People's Mental Health Services in England.

Almost a quarter of children and young people (CYP) in England have a long-term health condition (LTC), which increases the risk of developing mental health difficulties. There is a lack of understanding regarding the routine provision and efficacy of mental health interventions for CYP with LTCs within Children and Young People's Mental Health Services (CYPMHS). This study analysed national service-reported data in England from two secondary datasets. Data were submitted by services between 2011 and 2019. We evaluated data on the presence or absence of a serious physical health or neurological issue, and which interventions were offered. A total of 789 CYP had serious physical health issues and 635 had neurological issues. The most common interventions delivered to CYP in either group have some evidence in the literature. Most CYP showed improvements across a range of outcomes. This study found that prevalence rates and psychological intervention and outcome data were widely under-reported across both datasets, posing questions about their utility for this population. Such data would benefit from triangulation with data from other sources to understand pathways of care for these young people and the extent to which clinical datasets underreport the number of CYP with LTCs.

Experiences of clinical staff who work with patients who self-harm by ligature: An exploratory survey of inpatient mental health service staff.

Self-harm by ligature is common within inpatient mental healthcare settings and is a dangerous method of self-harm. Most fatal and non-fatal suicidal behaviours in inpatient settings are a result of ligature use. There is a lack of research which has explored the experiences of staff members who work within inpatient settings where patients may self-harm by ligature. Key issues related to self-harm by ligature reported by staff included (1) understaffing increasing risk of ligature incidents, (2) spreading of self-harm by ligature within inpatient settings and (3) negative attitudes of staff related to patients who self-harm by ligature. Working with self-harm by ligature can have negative impacts on staff's personal (e.g. fear of blame) and professional lives (e.g. increased cautiousness). Many staff members currently feel underprepared by training related to working with self-harm by ligature, and unsupported after responding to a ligature incident. Training about self-harm by ligature needs to be improved and be accessible for all inpatient mental healthcare staff. Training should be coproduced, and could include practical components, education on potential reasons for self-harm, and acknowledgement of the emotional impact on staff. Support for staff members who respond to ligature incidents should be available for all staff members who respond to self-harm by ligature incidents. Stigma associated with accessing support should be challenged, alongside blame cultures within the workplace. INTRODUCTION: Self-harm by ligature is a common form of self-harm within inpatient mental health services in England, where most suicides within inpatient settings involve hanging or suffocation. However, little research has examined the experiences of staff members working with this method of self-harm. We explored the experiences of clinical staff who work with patients who self-harm by ligature. A staff survey was developed and disseminated to clinical staff working in inpatient settings in England. Quantitative data were analysed using descriptive statistics, and qualitative data using the framework approach. The study was STROBE checklist compliant. 275 staff members participated. Challenges most frequently reported about working with self-harm by ligature included understaffing (210, 76.6%), spreading of ligature incidents (198, 72.8%) and negative attitudes held by clinical staff towards such patients (185, 68.5%). Participants' responses indicated that this work could have significant impacts on their professional and personal lives. Staff often reported inadequate training and lack of preparedness, alongside insufficient support opportunities following ligature incidents. Staff had a diverse range of professional and personal experiences and identified multiple challenges associated with working with patients who have self-harmed by ligature. There is a need to improve accessibility, format and content of training and support for staff working within inpatient settings where patients may self-harm by ligature.

Reproducing differential racialisation: social triage in migrant mental health services in England

Abstract In England, coverage for treatment of post-traumatic stress disorder (PTSD), a health condition that disproportionately affects forced migrants, is universal, in principle provided free of charge to all. Yet, multiple informal access barriers typically arise and informal systems of social triage may emerge. Using intersectional analysis, this study asks what political and moral rationalities inform social triage in the NHS. It is particularly attentive to how and why a supposedly universal service reproduces differential racialisation, in which multiple and co-existing populations are stratified and ranked as more or less belonging to a nation. Fieldwork was conducted in two waves, in 2015-2016 and in 2019-2021. It included six months of participant observation in an NGO; 21 semi-structured interviews with health professionals across 16 different NHS and NGO service providers, purposively sampled until saturation was reached; six interviews with mental health commissioners and national policymakers; and analysis of grey literature. Transcripts and fieldnotes were analysed inductively to identify themes using NvivoR1. Results were validated by interviewees. Despite being covered, undocumented migrants and asylum seekers were systematically excluded from NHS PTSD services, through social triage. People with refugee status were prioritised. Mental health care providers consciously and subconsciously reproduced differential racialisation, which generated health inequality. This was facilitated by: austerity; omitting immigration status in measurement of health inequality; securitisation of mental health services and minoritised Muslim populations; and bifurcated activism in which the forced migrant sector was disconnected from established struggles to combat racism in mental health care. Policies extending coverage to undocumented migrants and asylum seekers must be accompanied by extra monitoring, as well as financial, political and social support to service providers. Key messages • Health professionals informally, but systematically, reproduce differential racialisation in the rationing of health care through practices such as obfuscation and silencing critique. • Informal systems of social triage erode universal health coverage. This is exacerbated in contexts of austerity, where health professionals use their discretion to ration limited resources.

Experiences of ethnic minoritised young people in a specialist child and adolescent mental health service: A qualitative analysis as part of a mixed methods service evaluation.

There have been several reports of inequalities for ethnic minoritised service users across National Health Service mental health services in the United Kingdom. This research aims to explore the perspectives and experiences of young people from ethnic minoritised groups accessing psychological therapy in a National Specialist Child and Adolescent Mental Health Service in England. Semi-structured interviews were conducted to investigate how young people perceived their ethnicity and how it was considered during psychological therapy. Nine young people were interviewed, and a thematic analysis was conducted. Qualitative analysis revealed five themes: (1) adolescence, ethnicity, and identity; (2) ethnicity as a meaningful part of the therapeutic intervention; (3) therapeutic alliance to facilitate dialogue; (4) aversion to ethnicity exploration; and (5) treading lightly: a fine line between sensitive and overly cautious. The study illustrated the complexity of considering ethnicity in therapy due to conflicting views and preferences and the need for further research.

How clinical psychologists respond to child safeguarding dilemmas: A qualitative study

AbstractThis research aimed to explore how clinical psychologists respond to child safeguarding dilemmas, with special attention to the role of psychology in child welfare. Transcripts from 20 semi‐structured interviews with clinical psychologists working in Child and Adolescent Mental Health Services in England were analysed using a qualitative framework approach. In these interviews, two family case vignettes were used to examine how psychologists respond to child safeguarding dilemmas. We identified three overarching themes: operating within a system of stretched resources; characterising who is considered ‘supportable’ by psychological services; and challenges around conceptualising and responding to risk. Clinical psychologists viewed social services as responsible for family cases with safeguarding concerns and were reluctant to engage in high‐risk cases where stability in the home was not yet established. They saw their role in child welfare primarily as sense‐makers for families, by offering a contextualised explanation/formulation for the presenting difficulties.

An Overview of the Mental Health Services in England and the Role of the Psychotherapist in this Context

The article discusses the increasing prevalence of antidepressant use in the UK and concerns surrounding the reliance on psychotropic medication. The impact of the COVID-19 pandemic on mental health is also mentioned, along with the increasing rates of probable mental disorders in children and young people.

A national survey of current provision of waiting list initiatives offered by child and adolescent mental health services in England

Background: Children and young people accessing child and adolescent mental health services (CAMHS) often report delays in receiving an assessment and commencing treatment. In 2018, the James Lind Alliance acknowledged developing CAMHS waiting-list interventions (WLI) as a top 10 priority. Aims: This study aimed to examine the current provision of WLI in CAMHS. Methods: During 2021, an online survey was sent to each National Health Service (NHS) trust providing CAMHS in England, to explore provision of WLI within their trust. Findings: Of the 57 CAMHS trusts identified as meeting inclusion criteria, survey responses were received from 16 trusts, 12 of which had implemented WLI, a large proportion of these were digital interventions. Barriers and facilitators to WLIs were identified, particularly availability of staff. Conclusions: WLIs are being used in some trusts but with limited evidence of evaluation, further research on the acceptability and effectiveness of WLI is warranted.

The COSI trial: a study protocol for a multi-centre, randomised controlled trial to explore the clinical and cost-effectiveness of the Circle of Security-Parenting Intervention in community perinatal mental health services in England

BackgroundPerinatal mental health difficulties affect up to 27% of birthing parents during pregnancy and the first postnatal year, and if untreated are associated with difficulties in bonding and long-term adverse outcomes to children. There are large evidence gaps related to psychological treatment, particularly in group therapy approaches and parent-infant interventions. One intervention showing preliminary efficacious findings and user acceptability is Circle of Security-Parenting (COS-P), which is a brief, weekly, group programme. However, these studies were underpowered and predominantly non-randomised, and there has never been a research trial in England or with birthing parents experiencing severe and complex perinatal mental health difficulties. The aim of the research is to conduct a randomised control trial to test whether COS-P will reduce perinatal mental health symptoms in birthing parents accessing NHS perinatal mental health services, compared to treatment as usual (TAU). Secondary objectives include exploring whether the intervention improves parenting sensitivity, emotion regulation skills, attachment security and infant development. Additionally, the project aims to examine whether the intervention is acceptable to parents and NHS staff, and whether it is cost-effective.MethodsCOSI is an individually randomised, single-blind parallel arm controlled trial with an embedded internal pilot aiming to recruit 369 participants in a 2:1 ratio (intervention: TAU). Participants will be recruited from ten NHS community perinatal mental health services in England and screened based on clinical levels of both mental health symptoms (average CORE-OM score ≥ 1.1) and postnatal bonding difficulties (total PBQ score ≥ 12). This trial has 90% power to detect a MCID of 5 points on the CORE-OM. Primary and secondary outcomes will be measured at baseline, 3, 7 and 12 months after baseline. Service use and quality of life measures will also be collected alongside a process evaluation of parents’ and interveners’ views and experiences.DiscussionThis will be the first large pragmatic trial to test whether COS-P is effective for birthing parents with severe and complex perinatal mental health difficulties in improving their mental health symptoms. If shown to be effective, the intervention could be delivered widely across the NHS and other similar services globally.Trial registrationISRCTN, ISRCTN18308962. Registered 18 February 2022.

NHS mental health services' policies on leave for detained patients in England and Wales: A national audit.

INTRODUCTION: Considerable guidance is available about the implementation of leave for detained patients, but individual mental health services are free to determine their own policies. To determine how consistent leave policies of NHS mental health services in England and Wales are with relevant guidance and legislation. A national audit of NHS mental health services leave policies. Data were obtained through web searching and Freedom of Information requests. Policies were assessed against 65 criteria across four domains (administrative, Responsible Clinician, types of leave and nursing). Definitions of leave-related terms were extracted and analysed. Fifty-seven (91.9%) policies were obtained. There were considerable inconsistencies in how policies were informed by relevant guidance: Domain-level consistency was 72.3% (administrative), 64.0% (Responsible Clinician), 44.7% (types of leave) and 41.9% (nursing). Definitions varied widely and commonly differed from those in relevant guidance. Mental health professionals are inconsistently supported by the policy in their leave-related practice. This could potentially contribute to inconsistent practice and leave-related patient outcomes. To ensure patients are treated fairly clinicians need to be aware of their responsibilities around leave. In some services, they will need to go beyond their organization's stated policy to ensure this occurs.

Barriers to the management of sexual dysfunction among people with psychosis: analysis of qualitative data from the REMEDY trial

BackgroundMore than half of people who use antipsychotic medication for psychosis report having sexual dysfunction. The REMEDY trial aimed to find out if switching antipsychotic medication provides an effective way to reduce sexual dysfunction among people with psychosis. We set out to recruit 216 participants over a two-year period, but recruitment was stopped after an extended 12-month pilot phase, during which we recruited only 10 participants. As part of a nested process evaluation, we conducted qualitative interviews with front-line clinicians to examine barriers to recruitment to the trial.MethodsWe developed a semi-structured interview schedule to explore staff views on factors that influenced whether they referred potential participants to the study. We interviewed a purposive sample of 51 staff from four National Health Service (NHS) Trusts in England, ensuring a range of different backgrounds, seniority, and levels of involvement in the trial. Audio recordings of interviews were transcribed for verbatim, and data were analysed using an inductive approach to thematic analysis.ResultsNine interconnected themes were generated. Six themes concerned barriers to recruitment; including; prioritising patients’ mental stability, mutual discomfort and embarrassment about discussing a “taboo” subject, and concerns about unintended consequences of asking people with psychosis about their sexual functioning. Three themes, including the quality of treatment relationships and strategies for opening dialogue suggested ways to improve recognition of these “hidden” side effects.ConclusionThe identification and management of sexual dysfunction among people with psychosis are not priorities for mental health services in England at this time. Many staff working in front-line services feel unprepared and uncomfortable asking people with psychosis about these problems. While greater use of screening tools may improve the identification of sexual dysfunction among people with psychosis, the evaluation and implementation of interventions to manage them will continue to be challenging unless NHS leaders and senior clinicians demonstrate greater commitment to changing current clinical practice.Trial registrationCurrent Controlled Trials ISRCTN12307891.