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Fleury MJ, Imboua A, Grenier G. Barriers and Facilitators to High Emergency Department Use Among Patients with Mental Disorders: A Qualitative Investigation. Community Ment Health J 2024; 60:869-884. [PMID: 38383882 DOI: 10.1007/s10597-024-01239-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/17/2024] [Indexed: 02/23/2024]
Abstract
This qualitative study explored reasons for high emergency department (ED) use (3 + visits/year) among 299 patients with mental disorders (MD) recruited in four ED in Quebec, Canada. A conceptual framework including healthcare system and ED organizational features, patient profiles, and professional practice guided the content analysis. Results highlighted insufficient access to and inadequacy of outpatient care. While some patients were quite satisfied with ED care, most criticized the lack of referrals or follow-up care. Patient profiles justifying high ED use were strongly associated with health and social issues perceived as needing immediate care. The main barriers in professional practice involved lack of MD expertise among primary care clinicians, and insufficient follow-up by psychiatrists in response to patient needs. Collaboration with outpatient care may be prioritized to reduce high ED use and improve ED interventions by strengthening the discharge process, and increasing access to outpatient care.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, 1033 Pine Avenue West, Montreal, QC, H3A 1A1, Canada.
- Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada.
| | - Armelle Imboua
- Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
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Lamb D, Milton A, Forsyth R, Lloyd-Evans B, Akther S, Fullarton K, O'Hanlon P, Johnson S, Morant N. Implementation of a crisis resolution team service improvement programme: a qualitative study of the critical ingredients for success. Int J Ment Health Syst 2024; 18:18. [PMID: 38704589 PMCID: PMC11069280 DOI: 10.1186/s13033-024-00638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Crisis Resolution Teams (CRTs) offer home-based care for people in mental health crisis, as an alternative to hospital admission. The success of CRTs in England has been variable. In response to this, the CRT Optimization and RElapse prevention (CORE) study developed and trialled a 12-month Service Improvement Programme (SIP) based on a fidelity model. This paper describes a qualitative evaluation of the perspectives of CRT staff, managers, and programme facilitators. We identify barriers and facilitators to implementation, and mechanisms by which service improvements took place. METHODS Managers and staff from six purposively sampled CRTs were interviewed, as well as six facilitators who were employed to support the implementation of service improvement plans. Semi-structured focus groups and individual interviews were conducted and analysed using thematic analysis. FINDINGS A majority of participants viewed all components of the SIP as helpful in improving practice, although online resources were under-used. Perceived barriers to implementation centred principally around lack of staff time and ownership. Support from both senior staff and facilitators was essential in enabling teams to undertake the work associated with the SIP. All participating stakeholder groups reported that using the fidelity model to benchmark their CRT work to best practice and feel part of a 'bigger whole' was valuable. CONCLUSION CRT staff, managers and programme facilitators thought that a structured service improvement programme helped to increase fidelity to a best practice model. Flexibility (from all stakeholders) was key to enable service improvement actions to be manageable within time- and resource-poor teams.
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Affiliation(s)
- Danielle Lamb
- Department of Applied Health Research, UCL, Gower Street, London, WC1E 6BT, UK.
| | - Alyssa Milton
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Gillard S, Anderson K, Clarke G, Crowe C, Goldsmith L, Jarman H, Johnson S, Lomani J, McDaid D, Pariza P, Park AL, Smith J, Turner K, Yoeli H. Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-221. [PMID: 38149657 DOI: 10.3310/pbsm2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations The availability and quality of data imposed limitations on the reliability of some analyses. Future work Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Steve Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - Katie Anderson
- School of Health and Psychological Sciences, City, University of London, London, UK
| | | | - Chloe Crowe
- Adult Acute Mental Health Services, North East London NHS Foundation Trust, London, UK
| | - Lucy Goldsmith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Jo Lomani
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Paris Pariza
- Improvement Analytics Unit, Health Foundation, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jared Smith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Yoeli
- School of Health and Psychological Sciences, City, University of London, London, UK
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Vázquez ID, Tintó AL, Arjona CH, Martínez MB, Díaz AC. Accompanying mental health problems at home: Preliminary data from a crisis resolution and home treatment team in Catalonia. J Psychiatr Ment Health Nurs 2023; 30:974-982. [PMID: 36964951 DOI: 10.1111/jpm.12918] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/05/2023] [Accepted: 02/22/2023] [Indexed: 03/27/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Home treatment teams help people in a mental health crisis to recover. The staff goes to the person's home, avoiding the need to go to the hospital and providing care in the person's environment. The teams have been created in our country in recent years, becoming part of the mental health care network. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The paper presents the functioning of a CRHTT, the type of care it provides, and the coordination with the rest of the care network. It also shows the clinical results obtained in the first two years since its creation, supporting the CRHTT's effectiveness in accompanying people with mental health crises and reducing the need for hospital care. The outstanding factors in the team operation were coordination fluidity with referral services (facilitating accessibility), a prolonged care time (about two months), and continuity of care during the CRHTT intervention (the same CRHTT professionals visited the user and the family at home) and upon discharge (CRHTT staff organized joint visits with the professionals who would care for the user and the family after home treatment). The CRHTT followed a person-centered orientation based on horizontality and dialogue. The CRHTT fostered the inclusion of the family and social network in the treatment and a deep understanding of the crisis considering social determinants. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Flexibility, approach to the person's environment, dialogue, shared decision-making, and the inclusion of the family and social network in the treatment are central factors in CRHTT functioning. It helps the person regain control over their life and enhance their resources to face possible future crises. Training in crisis management, community mental health and family care, and teamwork (which implies joint home visits and co-responsibility with the rest of the staff, user, and the family) are relevant for CRHTT professionals. ABSTRACT INTRODUCTION: Crisis resolution and home treatment teams (CRHTTs) provide intensive home care to people in a mental health crisis, becoming an increasingly widespread alternative to hospital admissions. However, there are wide variations in service delivery, organization, and outcomes, and little literature on how these teams work in clinical practice and different settings. AIM To share the organizational functioning, the therapeutic approach, and the outcomes obtained in a CRHTT in Catalonia, Spain. METHOD A descriptive analysis of the functioning of a home treatment team, the characteristics of the people served, and the clinical results from November 2017 to December 2019 are presented. RESULTS One hundred and five people were served, with an average stay of 57 days. And 55.24% were women, and the mean age was 41. Most people could overcome the crisis at home, and 5.71% required hospital admission during home care. A statistically significant improvement was observed in the results of the GAF and HoNOS scales at admission and discharge. DISCUSSION Despite reduced staff, home care was an alternative to hospital admission for most people treated. IMPLICATIONS FOR PRACTICE Flexibility, teamwork, and collaboration with the social network are relevant factors when accompanying the recovery process at home.
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Affiliation(s)
| | - Alba Luque Tintó
- Mental Health and Addictions Service, Fundació Sanitària Mollet, Barcelona, Spain
| | | | - Mar Bodas Martínez
- Mental Health and Addictions Service, Fundació Sanitària Mollet, Barcelona, Spain
| | - Antoni Corominas Díaz
- Mental Health and Addictions Service, Fundació Sanitària Mollet, Barcelona, Spain
- Department of Mental Health, Fundació Althaia, Manresa, Spain
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Le Novere M, Johnson S, Lloyd-Evans B, Marston L, Ambler G, Clarke CS, Osborn D, Lamb D, Hunter RM. Cost-effectiveness of peer-supported self-management for people discharged from a mental health crisis team: methodological challenges and recommendations. Front Psychiatry 2023; 14:1031159. [PMID: 37333912 PMCID: PMC10272352 DOI: 10.3389/fpsyt.2023.1031159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 04/27/2023] [Indexed: 06/20/2023] Open
Abstract
Background Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution. Methods Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively. Results Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained. Discussion There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes.
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Affiliation(s)
- Marie Le Novere
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Sonia Johnson
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Brynmor Lloyd-Evans
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Louise Marston
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, Faculty of Mathematical & Physical Sciences, University College London, London, United Kingdom
| | - Caroline S. Clarke
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - David Osborn
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Danielle Lamb
- Department of Applied Health Research, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Rachael Maree Hunter
- Department of Applied Health Research, Faculty of Population Health Sciences, University College London, London, United Kingdom
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Schwarz J, Wolff J, Heinze M, von Peter S, Habicht JL. How to measure staff continuity in intensive psychiatric home treatment: a routine data and single case analysis. Front Psychiatry 2023; 14:1166197. [PMID: 37229387 PMCID: PMC10204706 DOI: 10.3389/fpsyt.2023.1166197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Background Intensive forms of outreach mental health care (IOC) such as crisis resolution or home treatment teams are increasingly implemented as alternatives to inpatient admission, providing recovery-oriented treatment at home at comparable costs and outcomes. However, one issue with IOC is the lack of continuity regarding staff members who provide home visits, complicating relationship building and meaningful therapeutic exchange. The aim of this study is to validate existing primarily qualitative findings using performance data and to explore a possible correlation between the number of staff involved within IOC treatment and the service users' length of stay (LOS). Methods Routine data from an IOC team in a catchment area in Eastern Germany were analyzed. Basic parameters of service delivery were calculated and an in-depth descriptive analysis regarding staff continuity was performed. Further, an exploratory single case analysis was conducted, presenting the exact sequence of all treatment contacts for one case with low and one with high staff continuity. Results We analyzed 10.598 face-to-face treatment contacts based on 178 IOC users. The mean LOS was 30.99 days. About 75% of all home visits were conducted by two or more staff members simultaneously. Service users saw an average of 10.24 different staff per treatment episode. On 11% of the care days, only unknown staff, and on 34% of the care days at least one unknown staff member conducted the home visit. 83% of the contacts were performed by the same three staff members and 51% were made by one and the same staff member. A significant positive correlation (p = 0.0007) was found between the number of different practitioners seen by a service user in the first seven days of care and the LOS. Conclusion Our results suggest that a high number of different staff in the early period of IOC episodes correlates with an extended LOS. Future research must clarify the exact mechanisms of this correlation. Furthermore, it should be investigated how the multiple professions within IOC teams influence the LOS and the quality of treatment and what quality indicators may be suitable to ensure treatment processes.
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Affiliation(s)
- Julian Schwarz
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Center for Health Service Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
- Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Center for Health Service Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Juri Luis Habicht
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Holgersen KH, Pedersen SA, Brattland H, Hynnekleiv T. A scoping review of studies into crisis resolution teams in community mental health services. Nord J Psychiatry 2022; 76:565-574. [PMID: 35148238 DOI: 10.1080/08039488.2022.2029941] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE OF ARTICLE Crisis Resolution Teams (CRT) for rapid assessment and short-term treatment of mental health problems have increasingly been implemented internationally over the last decades. Among the Nordic countries, the CRT model has been particularly influential in Norway, where 'Ambulante akutteam (AAT)' is a widespread psychiatric emergency service for adult patients. However, the clinical practice of these teams varies significantly. To aid further development of the service and guide future research efforts, we carried out a scoping review to provide an up-to-date overview of research available in primary studies focusing on phenomena related to CRTs in English and Scandinavian literature. METHODS A systematic literature search was conducted in the bibliometric databases MEDLINE, Embase, PsychINFO, Scopus, and SveMed+. Included studies were thematically analyzed using a qualitative method. RESULTS The search identified 1516 unique references, of which 129 were included in the overview. Thematic analysis showed that the studies could be assigned to: (1) Characteristics of CRTs (k = 45), which described key principles or specific interventions; (2) Implementation of CRTs (k = 54), which were descriptive about implementation in different teams, or normative about what clinical practice should include; and (3) Effect of CRTs (k = 38). CONCLUSIONS The international research literature on CRTs or equivalent teams is extensive. Many sub-themes have been studied with various research methodologies. Recent studies provide a better evidence base for how to organize services and to select therapeutic interventions, but there is still a need for more controlled studies in the field.
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Affiliation(s)
- Katrine Høyer Holgersen
- Nidelv Community Mental Health Center, Tiller, Clinic of Mental Health, St Olavs Hospital, Trondheim, Norway.,Department of Psychology, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Sindre Andre Pedersen
- Library Section for Medicine and Health Sciences, NTNU University Library, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Heidi Brattland
- Nidelv Community Mental Health Center, Tiller, Clinic of Mental Health, St Olavs Hospital, Trondheim, Norway
| | - Torfinn Hynnekleiv
- Department for Acute Psychiatry and Psychosis Treatment, Psychiatric Health Services Division, Sykehuset Innlandet Trust, Reinsvoll, Norway
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Johnson S, Dalton‐Locke C, Baker J, Hanlon C, Salisbury TT, Fossey M, Newbigging K, Carr SE, Hensel J, Carrà G, Hepp U, Caneo C, Needle JJ, Lloyd‐Evans B. Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care. World Psychiatry 2022; 21:220-236. [PMID: 35524608 PMCID: PMC9077627 DOI: 10.1002/wps.20962] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.
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Affiliation(s)
- Sonia Johnson
- Division of PsychiatryUniversity College LondonLondonUK,Camden and Islington NHS Foundation TrustLondonUK
| | | | - John Baker
- School of Healthcare, University of LeedsLeedsUK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK,Department of PsychiatrySchool of Medicine, and Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
| | - Tatiana Taylor Salisbury
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK
| | - Matt Fossey
- Faculty of Health, Education, Medicine and Social CareAnglia Ruskin UniversityChelmsfordUK
| | - Karen Newbigging
- Department of PsychiatryUniversity of OxfordOxfordUK,Institute for Mental Health, University of BirminghamBirminghamUK
| | - Sarah E. Carr
- Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK
| | - Jennifer Hensel
- Department of PsychiatryUniversity of ManitobaWinnipegMBCanada
| | - Giuseppe Carrà
- Department of Medicine and SurgeryUniversity of Milano BicoccaMilanItaly
| | - Urs Hepp
- Integrated Psychiatric Services Winterthur, Zürcher UnterlandWinterthurSwitzerland
| | - Constanza Caneo
- Departamento de Psiquiatría, Facultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
| | - Justin J. Needle
- Centre for Health Services Research, School of Health Sciences, City, University of LondonLondonUK
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Ruud T, Holgersen KH, Hasselberg N, Siqveland J. Accessibility and interventions of crisis resolution teams: a multicenter study of team practices and team differences in Norway. BMC Psychiatry 2022; 22:350. [PMID: 35597926 PMCID: PMC9123690 DOI: 10.1186/s12888-022-03992-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/09/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Components of crisis resolution teams' (CRTs) practices have been defined in recommendations and a fidelity scale, and surveys have reported how team leaders describe CRT practices. However, studies on CRTs have not measured and reported details of the crisis intervention provided to individual service users. The present study aimed to measure how various components of CRT practice were provided to individual service users and differences in practice between CRTs. METHODS The study was exploratory and part of a prospective multicenter pre-post project on outcome of CRT treatment in Norway. Accessibility and intervention components of 25 CRTs were measured for 959 service users at the first contact after referral and in 3,244 sessions with service users. The data on CRT practice components were analyzed with descriptive statistics and factor analyses, and differences between teams were analyzed using ANOVA and calculating the proportion (intraclass correlation coefficient) of total variance that was due to differences between teams. RESULTS One-third of the service users had their first session with the CRT the day of referral and another third the following day. Treatment intensity was mean 1.8 sessions the first week, gradually decreasing over subsequent weeks. Three of ten sessions were conducted in the service user's home and six of ten in the team's location. Eight of ten sessions took place during office hours and two of ten in the evening. The CRT provided assessment and psychological interventions to all service users. Family involvement, practical support, and medication were provided to two of ten service users. Between CRTs, significant differences were identified for a substantial proportion of practice components and especially for several aspects of accessibility. Cluster analysis identified two clusters of CRTs with significant differences in accessibility but no significant differences in the use of intervention components. CONCLUSIONS Measurements of accessibility and interventions provided to individual service users gave a detailed description of CRT practices and differences between teams. Such measurements may be helpful as feedback on clinical practice, for studying and comparing crisis resolution team practices, and in future studies on the association between different outcomes and potential critical elements of crisis interventions.
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Affiliation(s)
- Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Katrine Høyer Holgersen
- grid.52522.320000 0004 0627 3560Nidelv Community Mental Health Center, Clinic of Mental Health, St. Olavs Hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nina Hasselberg
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Johan Siqveland
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
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Hasselberg N, Klevan TG, Weimand B, Uverud GM, Holgersen KH, Siqveland J, Ruud T. Similarities and differences between service users' and carers' experiences of crisis resolution teams in Norway: a survey. BMC Psychiatry 2022; 22:266. [PMID: 35421950 PMCID: PMC9011940 DOI: 10.1186/s12888-022-03928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 04/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crisis resolution team (CRT) care in adult mental health services is intended to provide accessible and flexible short-term, intensive crisis intervention to service users experiencing a mental health crisis and involve their carers (next of kin). Research on users' and especially carers' experiences with CRT care is scarce and is mostly qualitative in nature. METHODS Altogether, 111 service users and 86 carers from 28 Norwegian CRTs were interviewed with The Service User and Carer Structured Interviews of the CORE Crisis Resolution Team Fidelity Scale Version 2. Their experiences with different aspects of CRT care were reported with descriptive statistics, and differences between service users' and carers' experiences were analyzed with the Mann-Whitney U Test. RESULTS The service users and carers reported that the CRT care mostly reflected their needs and what they wanted. The experiences of service users and carers were mostly similar, except for significant differences in received information and how the termination of CRT care appeared. Both groups experienced the organization of the CRT care as accessible, with continuity, reliability, and flexibility, but without a high intensity of care. Both groups found the content of the CRT care supportive, sensitive, with a choice of treatment type and a range of interventions beyond medication, but a lack of written treatment plans and discharge plans. Carers were rarely involved in discharge meetings. Regarding the role of CRTs within the care system, both groups agreed upon the lack of facilitation of early discharge from inpatient wards and lack of home treatment, but both groups confirmed some collaboration with other mental health services. CONCLUSION Service users and carers found that the CRTs were accessible, reliable, flexible, supportive, sensitive, and provided a range of interventions beyond medication. Limitations were lack of a high intensity of care, limited written treatment and discharge plans, limited provision of home treatment, and lack of gatekeeping of acute beds. Both groups experienced the CRT care as mostly similar, but with significant differences regarding involvement in care planning and discharge preparation.
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Affiliation(s)
- Nina Hasselberg
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Trude Gøril Klevan
- grid.463530.70000 0004 7417 509XFaculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Bente Weimand
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.463530.70000 0004 7417 509XFaculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Gunn-Marit Uverud
- grid.463530.70000 0004 7417 509XUniversity of South-Eastern Norway, Notodden, Vestfold Norway
| | - Katrine Høyer Holgersen
- grid.52522.320000 0004 0627 3560Nidelv Community Mental Health Center, Clinic of Mental Health, St Olavs hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Siqveland
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
| | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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11
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Dalton-Locke C, Johnson S, Harju-Seppänen J, Lyons N, Sheridan Rains L, Stuart R, Campbell A, Clark J, Clifford A, Courtney L, Dare C, Kelly K, Lynch C, McCrone P, Nairi S, Newbigging K, Nyikavaranda P, Osborn D, Persaud K, Stefan M, Lloyd-Evans B. Emerging models and trends in mental health crisis care in England: a national investigation of crisis care systems. BMC Health Serv Res 2021; 21:1174. [PMID: 34711222 PMCID: PMC8553397 DOI: 10.1186/s12913-021-07181-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Inpatient psychiatric care is unpopular and expensive, and development and evaluation of alternatives is a long-standing policy and research priority around the world. In England, the three main models documented over the past fifty years (teams offering crisis assessment and treatment at home; acute day units; and residential crisis services in the community) have recently been augmented by several new service models. These are intended to enhance choice and flexibility within catchment area acute care systems, but remain largely undocumented in the research literature. We therefore aimed to describe the types and distribution of crisis care models across England through a national survey. Methods We carried out comprehensive mapping of crisis resolution teams (CRTs) using previous surveys, websites and multiple official data sources. Managers of CRTs were invited to participate as key informants who were familiar with the provision and organisation of crisis care services within their catchment area. The survey could be completed online or via telephone interview with a researcher, and elicited details about types of crisis care delivered in the local catchment area. Results We mapped a total of 200 adult CRTs and completed the survey with 184 (92%). Of the 200 mapped adult CRTs, there was a local (i.e., within the adult CRT catchment area) children and young persons CRT for 84 (42%), and an older adults CRT for 73 (37%). While all but one health region in England provided CRTs for working age adults, there was high variability regarding provision of all other community crisis service models and system configurations. Crisis cafes, street triage teams and separate crisis assessment services have all proliferated since a similar survey in 2016, while provision of acute day units has reduced. Conclusions The composition of catchment area crisis systems varies greatly across England and popularity of models seems unrelated to strength of evidence. A group of emerging crisis care models with varying functions within service systems are increasingly prevalent: they have potential to offer greater choice and flexibility in managing crises, but an evidence base regarding impact on service user experiences and outcomes is yet to be established. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07181-x.
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Affiliation(s)
- Christian Dalton-Locke
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Jasmine Harju-Seppänen
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Natasha Lyons
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Ruth Stuart
- NIHR Mental Health Policy Research Unit, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Amelia Campbell
- NIHR Mental Health Policy Research Unit Co-Production Group, Division of Psychiatry, University College London, London, UK
| | - Jeremy Clark
- Mental Health Policy Branch, Department of Health and Social Care, London, UK
| | | | - Laura Courtney
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Ceri Dare
- NIHR Mental Health Policy Research Unit Co-Production Group, Division of Psychiatry, University College London, London, UK
| | | | - Chris Lynch
- NIHR Mental Health Policy Research Unit Co-Production Group, Division of Psychiatry, University College London, London, UK
| | - Paul McCrone
- Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
| | - Shilpa Nairi
- Camden and Islington NHS Foundation Trust, London, UK
| | - Karen Newbigging
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Patrick Nyikavaranda
- NIHR Mental Health Policy Research Unit Co-Production Group, Division of Psychiatry, University College London, London, UK
| | - David Osborn
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Karen Persaud
- NIHR Mental Health Policy Research Unit Co-Production Group, Division of Psychiatry, University College London, London, UK
| | - Martin Stefan
- Southern District Health Board, Southern Health, Dunedin, New Zealand
| | - Brynmor Lloyd-Evans
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
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12
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Goldsmith LP, Anderson K, Clarke G, Crowe C, Jarman H, Johnson S, Lloyd-Evans B, Lomani J, McDaid D, Park AL, Smith JA, Turner K, Gillard S. The psychiatric decision unit as an emerging model in mental health crisis care: a national survey in England. Int J Ment Health Nurs 2021; 30:955-962. [PMID: 33630402 DOI: 10.1111/inm.12849] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Abstract
Psychiatric decision units have been developed in many countries internationally to address the pressure on inpatient services and dissatisfactory, long waits people in mental health crisis can experience in emergency departments. Research into these units lags behind their development, as they are implemented by healthcare providers to address these problems. This is the first-ever national survey to identify their prevalence, structure, activities, and contextual setting within health services, in order to provide a robust basis for future research. The response rate was high (94%), and six PDUs in England were identified. The results indicated that PDUs open 24/7, accept only voluntary patients, provide recliner chairs for sleeping rather than beds, and limit stays to 12-72 hours. PDUs are predominantly staffed by senior, qualified mental health nurses and healthcare assistants, with psychiatry input. Staff:patient ratios are high (1:2.1 during the day shift). Differences in PDU structure and activities (including referral pathway, length of stay, and staff:patient ratios) were identified, suggesting the optimal configuration for PDUs has not yet been established. Further research into the efficacy of this innovation is needed; PDUs potentially have a role in an integrated crisis care pathway which provides a variety of care options to service users.
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Affiliation(s)
- Lucy P Goldsmith
- Division of Nursing, School of Health Sciences, City, University of London, London, UK.,Population Health Research Institute, St George's, University of London, London, UK
| | - Katie Anderson
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
| | | | - Chloe Crowe
- North East London NHS Foundation Trust, CEME Centre- West Wing, Rainham, Essex, UK
| | - Heather Jarman
- Division of Nursing, School of Health Sciences, City, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Brynmor Lloyd-Evans
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Jo Lomani
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Jared A Smith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - Steve Gillard
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
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13
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Hasselberg N, Holgersen KH, Uverud GM, Siqveland J, Lloyd-Evans B, Johnson S, Ruud T. Fidelity to an evidence-based model for crisis resolution teams: a cross-sectional multicentre study in Norway. BMC Psychiatry 2021; 21:231. [PMID: 33947362 PMCID: PMC8094557 DOI: 10.1186/s12888-021-03237-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/16/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Crisis resolution teams (CRTs) are specialized multidisciplinary teams intended to provide assessment and short-term outpatient or home treatment as an alternative to hospital admission for people experiencing a mental health crisis. In Norway, CRTs have been established within mental health services throughout the country, but their fidelity to an evidence-based model for CRTs has been unknown. METHODS We assessed fidelity to the evidence-based CRT model for 28 CRTs, using the CORE Crisis Resolution Team Fidelity Scale Version 2, a tool developed and first applied in the UK to measure adherence to a model of optimal CRT practice. The assessments were completed by evaluation teams based on written information, interviews, and review of patient records during a one-day visit with each CRT. RESULTS The fidelity scale was applicable for assessing fidelity of Norwegian CRTs to the CRT model. On a scale 1 to 5, the mean fidelity score was low (2.75) and with a moderate variation of fidelity across the teams. The CRTs had highest scores on the content and delivery of care subscale, and lowest on the location and timing of care subscale. Scores were high on items measuring comprehensive assessment, psychological interventions, visit length, service users' choice of location, and of type of support. However, scores were low on opening hours, gatekeeping acute psychiatric beds, facilitating early hospital discharge, intensity of contact, providing medication, and providing practical support. CONCLUSIONS The CORE CRT Fidelity Scale was applicable and relevant to assessment of Norwegian CRTs and may be used to guide further development in clinical practice and research. Lower fidelity and differences in fidelity patterns compared to the UK teams may indicate that Norwegian teams are more focused on early interventions to a broader patient group and less on avoiding acute inpatient admissions for patients with severe mental illness.
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Affiliation(s)
- N. Hasselberg
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - K. H. Holgersen
- grid.52522.320000 0004 0627 3560Tiller Community Mental Health Centre, Department of Mental Health, St. Olavs Hospital, Trondheim, Norway
| | - G. M. Uverud
- grid.463530.70000 0004 7417 509XUniversity of South-Eastern Norway, Vestfold, Norway
| | - J. Siqveland
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
| | - B. Lloyd-Evans
- grid.83440.3b0000000121901201Division of Psychiatry, University College London, London, UK
| | - S. Johnson
- grid.83440.3b0000000121901201Division of Psychiatry, University College London, London, UK
| | - T. Ruud
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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14
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Yates J, Stanyon M, Challis D, Coleston-Shields DM, Dening T, Hoe J, Jawahar K, Lloyd-Evans B, Moniz-Cook E, Poland F, Streater A, Trigg E, Orrell M. Developing a model of best practice for teams managing crisis in people with dementia: a consensus approach. BMC Psychiatry 2020; 20:505. [PMID: 33050901 PMCID: PMC7552369 DOI: 10.1186/s12888-020-02899-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Teams delivering crisis resolution services for people with dementia and their carers provide short-term interventions to prevent admission to acute care settings. There is great variation in these services across the UK. This article reports on a consensus process undertaken to devise a Best Practice Model and evaluation Tool for use with teams managing crisis in dementia. METHODS The Best Practice Model and Tool were developed over a three stage process: (i) Evidence gathering and generation of candidate standards (systematic review and scoping survey, interviews and focus groups); (ii) Prioritisation and selection of standards (consultation groups, a consensus conference and modified Delphi process); (iii) Refining and operationalising standards (consultation group and field-testing). RESULTS One hundred sixty-five candidate standards arose from the evidence gathering stage; were refined and reduced to 90 through a consultation group exercise; and then reduced to 50 during the consensus conference and weighted using a modified Delphi process. Standards were then operationalised through a clinical consultation group and field-tested with 11 crisis teams and 5 non-crisis teams. Scores ranged from 48 to 92/100. The median score for the crisis teams was 74.5 (range 67-92), and the median score for non-crisis teams was 60 (range 48-72). CONCLUSIONS With further psychometric testing, this Best Practice Model and Tool will be ideal for the planning, improvement and national benchmarking of teams managing dementia crises in the future.
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Affiliation(s)
- Jennifer Yates
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK.
| | - Miriam Stanyon
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - David Challis
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Donna Maria Coleston-Shields
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Tom Dening
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Juanita Hoe
- Division of Nursing, City University London, London, UK
| | - Kaanthan Jawahar
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | | | | | | | - Amy Streater
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
- Research and Development, North East London NHS Foundation Trust, Ilford, UK
| | - Emma Trigg
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Martin Orrell
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
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