UK Mental Health Services Research Articles

Mental Health Risk Assessment and Safety Planning During UK Covid-19 Pandemic Lockdown: Mixed Methods Survey and Interview Study

Risk assessment and safety planning are central to mental health nursing practice but were seriously affected by the Covid-19 pandemic and associated lockdowns. In this study, we aimed to explore how the UK pandemic lockdowns affected risk assessment and safety planning from the perspective of mental health practitioners. A sequential, mixed methods study design was used. A link to an online survey questionnaire was distributed and semi-structured interviews with a subset of respondents were conducted. Survey data were analysed to describe perceived changes in the frequency and nature of risk assessment and safety planning during the pandemic lockdowns. This was supplemented by thematic analysis of qualitative interview data. In total, 106 practitioners were surveyed and 10 participated in semi-structured interviews. More respondents increased than decreased risk assessment frequency but there was no significant overall change. Remote contact was more common in community settings and largely involved telephone appointments. Participants did not wish to continue with remote working following the pandemic. Risk assessment practice changed in UK mental health services as a result of COVID-19 lockdowns.

Online peer support groups for individuals who hear voices: protocol for a nonrandomised feasibility study

ABSTRACT Background Hearing Voices Groups (HVGs) have proliferated internationally. They are premised on the notion that connections between peers facilitate personal recovery. Little systematic research exists into if, and how, HVGs may be effective, especially when convened online. This paper aims to harmonise standardised research methodology with the liberatory, survivor-led ethos of many HVGs to outline a protocol for the first longitudinal, nonrandomised trial of an online HVG to take place within UK mental health services. Methods Six to ten adults who hear voices will be recruited from both community and UK National Health Service (NHS) settings to participate in a six-month peer-support group that is delivered via videoconference. Participants will complete questionnaires assessing social support, voice-hearing and feelings of personal recovery and qualitative interviews at baseline and at the end of the group. Participants will also complete measures of group cohesion at weeks 4 and 12. Results Data will be analysed for feasibility, acceptability and safety. Discussion This is the first longitudinal study evaluating the feasibility and acceptability of an online HVG held within the NHS. The findings may provide insights into the impact of such interventions and inform the design of a future, definitive study.

"What Works" to Support LGBTQ+ Young People's Mental Health: An Intersectional Youth Rights Approach.

Despite overwhelming international evidence of elevated rates of poor mental health in LGBTQ+ youth compared to their cis-heterosexual peers, we know relatively little about effective mental health services for this population group. This study aims to produce the first early intervention model of "what works" to support LGBTQ+ youth with emerging mental health problems. Utilizing a mixed method case study, we collected data across 12 UK mental health service case study sites that involved: (a) interviews with young people, parents, and mental health practitioners (n = 93); (b) documentary analysis; (c) nonparticipant observation. The data analysis strategy was theoretical using the "explanation-building" analytical technique. Our analysis suggests an intersectional youth rights approach with 13 principles that must be enacted to provide good mental health services as advocated by the United Nations Convention on the Rights of the Child and World Health Organization. This approach should address the multiple forms of marginalization and stigmatization that LGBTQ+ youth may experience, enable informed independent decision-making, and uphold the right to freedom of safe self-expression. A rights-based approach to mental health services for LGBTQ+ young people is not prominent. This needs to change if we are to tackle this mental health inequality and improve the mental well-being of LGBTQ+ youth worldwide.

Escaping iatrogenic harm: A journey into mental health service avoidance.

WHAT IS KNOWN ON THE SUBJECT?: Little is known about how mental health services can cause harm in ways other than medication, talking therapies, diagnosis and detention under the Mental Health Act. The outcomes of people who avoid seeking help from mental health services due to previous experiences of harm are not well known. WHAT THIS ARTICLE ADDS TO EXISTING KNOWLEDGE?: I provide a first-person perspective of experiences of harm within mental health services, how this impacted my care, the long-term effects of the harm on my well-being and my ongoing experiences of avoiding mental health services. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING?: Healthcare professionals should be aware of the multitude of ways service provision can harm patients, and how, unknown to professionals, patients may create an internal understanding of how to best navigate harmful service environments. Healthcare professionals should have a deeper understanding of the reasons why people may choose not to engage with mental health services, and what impact this may have on them. ABSTRACT: The recent announcement of the first ever statutory public inquiry into a UK mental health service indicates a growing recognition of iatrogenic harm in mental healthcare. Despite the potential for harm across all services and practices, restrictive practices, psychotherapy, diagnosis and psychiatric medications are often the only areas of mental healthcare given significant attention. While the topic is widely discussed in survivor communities, accounts of harm caused by the everyday workings of services, including team cultures, administrative processes and staff-patient interactions, are missing from academic literature. In this article, I describe my 10-year journey through mental health services, and how everyday practices, cultures and staff behaviour deeply impacted my ability to receive appropriate care, replicated previously traumatic environments, and damaged my mental health. Taking steps to protect myself from further harm, I self-discharged and am currently living as a 'service-avoider'. The ongoing implications of this decision and the long-term impacts of harm are discussed.

Designing a Library of Lived Experience for Mental Health: integrated realist synthesis and experience-based co-design study in UK mental health services

ObjectiveLiving Library events involve people being trained as living ‘Books’, who then discuss aspects of their personal experiences in direct conversation with attendees, referred to as ‘Readers’. This study sought...

Assessment of machine learning algorithms in national data to classify the risk of self-harm among young adults in hospital: A retrospective study

Self-harm is one of the most common presentations at accident and emergency departments in the UK and is a strong predictor of suicide risk. The UK Government has prioritised identifying risk factors and developing preventative strategies for self-harm. Machine learning offers a potential method to identify complex patterns with predictive value for the risk of self-harm. National data in the UK Mental Health Services Data Set were isolated for patients aged 18-30years who started a mental health hospital admission between Aug 1, 2020 and Aug 1, 2021, and had been discharged by Jan 1, 2022. Data were obtained on age group, gender, ethnicity, employment status, marital status, accommodation status and source of admission to hospital and used to construct seven machine learning models that were used individually and as an ensemble to predict hospital stays that would be associated with a risk of self-harm. The training dataset included 23 808 items (including 1081 episodes of self-harm) and the testing dataset 5951 items (including 270 episodes of self-harm). The best performing algorithms were the random forest model (AUC-ROC 0.70, 95%CI:0.66-0.74) and the ensemble model (AUC-ROC 0.77 95%CI:0.75-0.79). Machine learning algorithms could predict hospital stays with a high risk of self-harm based on readily available data that are routinely collected by health providers and recorded in the Mental Health Services Data Set. The findings should be validated externally with other real-world, prospective data. This study was supported by the Midlands and Lancashire Commissioning Support Unit.

Navigating advanced nurse practitioner roles in UK mental health services: a scoping review

Background: The advanced nurse practitioner (ANP) role is becoming increasingly prominent in the provision of mental health services, both in the UK and globally. Understanding the experiences associated with these roles is crucial for their effective implementation in practice. This article presents a scoping review that systematically searches and synthesises existing literature on the experiences of ANP roles in mental health services in the UK. Methods: A comprehensive search of databases including CINAHL, MEDLINE, Web of Science, PsychNet, and Google Scholar was conducted to identify relevant peer-reviewed publications and grey literature that had been published between 2010 and 2022. The Patterns, Advances, Gaps, Evidence for Practice, Research recommendations (PAGER) framework was employed to analyse the findings and identify key themes. Findings: The review findings reveal important insights into the experiences of ANP roles in mental health services, highlighting the significance of role understanding, opportunities and challenges. Key themes identified include the need for clear governance, role clarity, support from colleagues and managers, professional development opportunities, and the impact of role implementation on the provision of person-centred care and physical healthcare. Conclusion: ANP roles in mental health services offer opportunities to enhance the provision of person-centred care, improve physical healthcare delivery and provide professional development and career pathways for nurses. However, challenges such as role understanding, planning and support need to be addressed to ensure successful implementation. Further research examining patient experiences, measures to support improved planning and role clarity, and the professional development and career pathways of ANPs would contribute to advancing the field and facilitating the effective future implementation of ANP roles in mental health services in the UK and beyond.

Realist synthesis of factors affecting retention of staff in UK adult mental health services

ObjectivesThe shortage of healthcare staff is a global problem. UK mental health services have, on average, a higher turnover of staff than the NHS. Factors affecting retention of this staff...

​​Nested Ethics: The Management of Young People’s Goals in Alternative UK Mental Health Services

Youth mental health interventions in the UK increasingly use goal-setting procedures to shape services and measure outcomes in ways that are intended to be meaningful to service users. This research article questions this premise, departing with the ethnographic observation that many young people do not seem to welcome the invitation or requirement to direct their therapeutic aims and set the terms for service evaluation in the form of goals. I will show that goal-setting procedures are examples of a broader field of complex ethico-political dilemmas navigated by mental health service staff. While wanting to enable young people to be healthy agents, staff are simultaneously critically aware of the risk of imposing normative, unrealistic and unfair expectations onto young people. I propose that these staff are engaged in a specific form of ethico-political practice, which I call ‘nested ethics’. I use this term to describe instances where staff ethically evaluate their own conduct in line with the capacity to enable the ethical life of another person (youth, in this case). Viewing goal-setting processes as an example of an uneasy politics of nested ethics enables a new perspective from which to advance debates about the enablement of service user choice within care provisions.

Prescribing clozapine in the UK: Quality improvement issues identified by clinical audit.

Introduction:The Prescribing Observatory for Mental Health initiated a quality improvement (QI) programme on clozapine use in UK mental health services.Methods:Clinical audits conducted in 2019 and 2021.Results:Sixty-three participating NHS Trusts/healthcare organisations in 2019, and 61 in 2021, submitted treatment data for 6948 and 8155 patients, respectively. In both audits, high-dose and/or combined antipsychotic medications had been prescribed immediately before initiating clozapine in over a quarter of patients recently started on clozapine. In patients who were tobacco smokers and recently discharged from a smoke-free ward, the impact of the potential change in smoking status had been considered in the care plans of just under one-third in 2019 and just over a half in 2021. For community patients, their Summary Care Records (SCRs) included their clozapine prescriptions in 58% of cases in 2019 and 72% in 2021.Conclusions:Three QI issues were identified. (1) Antipsychotic regimens with limited evidence for efficacy in treatment-resistant schizophrenia were prescribed for over a quarter of cases before starting clozapine. Use of such strategies may delay clozapine treatment, potentially reducing the likelihood of a therapeutic response. (2) While anticipation of the consequences of a change in smoking status on plasma clozapine concentration following discharge from hospital showed improvement over time, even in 2021 it was not evident for nearly a half of relevant cases. (3) While inclusion of clozapine in the SCR also improved over time, even in 2021 it was missing for more than a quarter of community patients.

Making Good of Crisis: Temporalities of Care in UK Mental Health Services

ABSTRACT A paradoxical concept of crisis has come to dominate contemporary understandings of suffering and care: as that which will reach a critical turning point, while also being chronic and enduring. I analyze this temporal enigma through an ethnography of mental health care practitioners in the UK who see themselves as embedded in a crisis-stricken care system, yet attempt to reformulate their therapeutic approach to crisis in productive ways: to make “good” of crisis. I argue that their efforts to make good in and of the temporal interstices of crisis disclose care as temporally unstable as well as ethically ambivalent.

Who is prescribed valproate and how carefully is this treatment reviewed in UK mental health services? Data from a clinical audit.

Background:The licensed indications for valproate are narrow, yet this medication is commonly prescribed in mental health services.Objectives:To explore the target symptoms/behaviours for which valproate is prescribed and how well the efficacy and tolerability of this treatment are monitored in routine clinical practice.Design:An audit-based quality improvement (QI) programme in UK mental health services.Methods:Information on valproate prescribing was collected from clinical records using a bespoke data collection tool.Results:Sixty-four NHS mental health Trusts/healthcare organisations submitted data on valproate treatment for 5320 patients. Valproate was clearly prescribed for a licensed indication in 1995 (38%) patients, off-label in 1987 (37%) while the indication was uncertain/not available in 1338 (25%). Of the 919 patients started on valproate treatment within the past year, between a half and two-thirds had each of the relevant baseline physical health checks documented. In 539 (59%) of these patients, valproate was prescribed for an unlicensed indication; the prescription was recognised as off-label in 363 (67%), 20 (6%) of whom were documented as having had this explained to them. Of 631 patients prescribed valproate for between 3 months and a year, early on-treatment assessments of response and side effects were documented in 441 (70%) and 332 (53%), respectively. Of 4401 patients treated for more than a year, annual on-treatment reviews of clinical response and side effects were documented in 2771 (63%) and 2140 (49%), respectively.Conclusion:Our data suggest the majority of prescriptions for valproate in mental health services are not for a licensed indication. Furthermore, patients rarely receive an explanation that their valproate prescription is off-label, perhaps partly because the licensed indications are not widely understood by prescribers. Given the very limited evidence for efficacy for the off-label uses of valproate, failure to routinely conduct early on-treatment and annual reviews of the benefits and side effects of this medication may result in patients remaining on ineffective and poorly tolerated treatment by default.

Dissociation in patients with non-affective psychosis: Prevalence, symptom associations, and maintenance factors

Dissociation is problematic in its own right for patients with psychosis but may also contribute to the occurrence of psychotic experiences. We therefore set out to estimate in a large cohort of patients with psychosis the prevalence of dissociative experiences, and assess using network models the relationships between dissociation, its potential maintenance mechanisms, and mental health symptoms.902 patients with non-affective psychosis attending UK mental health services participated. Both an undirected model and a partially directed network model were estimated to identify potential relationships between ‘felt sense of anomaly’ dissociative experiences, paranoia, hallucinations, psychological wellbeing, sleep, and six potential maintenance mechanisms (affect intolerance, perseverative thinking, general self-efficacy, alexithymia, cognitive appraisals, and cognitive-behavioural responses to dissociation).617 patients (65.4%) had experienced at least one dissociative symptom regularly over the past fortnight, with the average number experienced being 8.9 (SD = 8.0). Dissociation had direct relationships with paranoia, hallucinations, low psychological wellbeing, cognitive appraisals, cognitive-behavioural responses to dissociation, perseverative thinking, and low alexithymia. Dissociation was a probable cause of hallucinations (94.21% of 50,000 sampled directed acyclic graphs), with a trend towards also being a cause of paranoia (86.25% of 50,000 sampled directed acyclic graphs).Approximately two-thirds of patients with psychosis experience regular dissociative experiences. Dissociation is associated with low psychological wellbeing, and it is likely to have a direct causal influence on psychotic symptoms. Catastrophic cognitive appraisals, cognitive-behavioural responses to dissociation, factors related to affect sensitivity, and perseverative thinking may contribute to the occurrence of dissociation.

Incidence of suicidality in people with depression over a 10-year period treated by a large UK mental health service provider

Summary We describe the incidence of suicidality (2007–2017) in people with depression treated by secondary mental healthcare services at South London and Maudsley NHS Trust (n = 26 412). We estimated yearly incidence of ‘suicidal ideation’ and ‘high risk of suicide’ from structured and free-text fields of the Clinical Record Interactive Search system. The incidence of suicidal ideation increased from 0.6 (2007) to 1 cases (2017) per 1000 population. The incidence of high risk of suicide, based on risk forms, varied between 0.06 and 0.50 cases per 1000 adult population (2008–2017). Electronic health records provide the opportunity to examine suicidality on a large scale, but the impact of service-related changes in the use of structured risk assessment should be considered.

‘You don't take things too seriously or un‐seriously’: Beyond recovery to liminal and liminoid possibility in a community arts and mental health project

AbstractRecent years have seen a renewed interest in integrating creative activities into statutory mental health practice in high‐income countries. In this article, we offer an exploratory analysis of an arts project delivered within UK mental health services, Creativity for Enablement and Wellbeing (CREW). Drawing on data collected for a process evaluation of the project, we suggest that conceptualising CREW as liminal and liminoid provides a helpful way to articulate the processes, atmospheres, relationships, and practices of the project. Through this theoretical lens, we identify CREW as a mode of engagement comprising looseness, possibility and collectivity, all brought together through a unique community event, the showcase. We explore CREW's mode of engagement through three themes: ‘carving out a liminal space’, ‘looseness and experimentation,’ and ‘from liminal to liminoid’. Implications for service delivery are discussed, focussing on how CREW managed to create a transformative space of liminoid possibility rather than a recovery journey delineated by service‐defined imperatives.

Theorising worker–client relations in front‐line service work: Understanding the experience of non‐professionally affiliated workers in UK mental health services

AbstractThis paper contributes to a deeper understanding of front‐line service workers’ experience of the worker–client relationship. It is based on a series of in‐depth interviews with non‐professionally affiliated workers in new front‐line roles in UK mental health services. The findings cover three main areas: worker motivation and orientation; the nature of the worker–client relationship; and the role played in the relationship by the structure of work and relationships with colleagues. Evidence is found to support the use of the framework of Korczynski (Sociology, 43, 2009), but the research also suggests ways in which each of the framework's elements might be developed. It is argued that the idea of ‘caring’ is in need of refinement; that worker–client relations should not be seen solely in terms of client sovereignty and that a focus on the technical organisation of work can only go some way towards providing an understanding of the worker experience.

Management of demographic equality of access to family intervention for psychosis in specialist community mental healthcare teams

Background/AimsUK mental health services must provide evidence-based psychological treatments, including family intervention, to every service user diagnosed with psychosis. Although healthcare managers are required to ensure equitable delivery of prescribed core treatments, in practice equality of access remains debatable. This study investigates equality of access to family intervention for psychosis. Subsequent treatment uptake and engagement are also examined. The role of healthcare records in equality management is considered.MethodsRetrospective analysis of electronic medical records of 244 service users across four specialist early intervention teams in London in 2018 was undertaken using binary logistic regression and multiple linear regression. Bonferroni adjustment was applied to control for type 1 errors.ResultsParticipants were found to have equal access to the nationally endorsed treatment across all demographic variables. Likewise, treatment uptake and engagement were equally distributed.ConclusionsAn overall compliance with national policies was shown, demonstrating that equal provision of core treatment for psychosis is achievable. As discrepancies in record keeping were shown to impede the data extraction process, suggestions were made for the management of electronic medical records in mental healthcare services.

Cultural issues on accessing mental health services in Nepali and Iranian migrants communities in the UK.

Mental health in Black Asian and Minority Ethnic (BAME) communities is a rising public health concern in the UK, with key challenges around accessing mental health services. Our understanding of mental health issues in the growing Nepali and Iranian communities in the UK is very limited. Therefore, this study aims to explore the major factors affecting access to, and engagement with NHS mental health services. This study used a qualitative approach comprising in-depth interviews with seven Nepali, eight Iranians and six community mental health workers in the south of England. The data were analysed using a thematic approach. Six themes were identified: (1) stigma and fear; (2) gender; (3) language; (4) tradition and culture; (5) family involvement; and (6) lack of cultural awareness in health workers, all appearing to be major issues. This study contributes to a shared understanding of mental illness within two given cultural contexts to promote early interventions in UK mental health services. Developing cross-cultural perspectives in health care should be a priority in practice.

Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study - CORRIGENDUM.

Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study - CORRIGENDUM.

The social impact of COVID‐19 as perceived by the employees of a UK mental health service

This study explored the perceptions of NHS employees working within a UK mental health trust in relation to the social impacts of the COVID‐19 pandemic. Questioning focussed on social isolation and desire to interact with others before and since COVID‐19; effects of safety measures including personal protective equipment and social distancing; and perceived influences of the pandemic on service users and social aspects of service delivery. All employees at an English NHS mental health service were invited to complete an anonymous online questionnaire (July–September 2020), resulting in 464 completed questionnaires. Response frequencies were summed across the total sample, and the influence of patient contact, age, and vulnerability to COVID‐19 were explored using pairwise comparisons. Approximately two thirds of employees felt there had been a fundamental change in how they felt about interacting with others, and many had lost confidence in their ability to relate emotionally to others. Respondents were keen to adhere to safety guidance, but the majority believed that face masks and social distancing could have a detrimental effect on communication and rapport within the workplace. Other concerns included passing on the virus, social isolation of employees and service users, and a reduction in community services. COVID‐19 safety measures may impact morale, communication, empathy, and the provision of client‐centred care. More generally, the pandemic has changed the attitudes of mental health workers towards social interaction, with younger employees reporting more mental health difficulties that may be linked to concerns about longer term social change.