Specialised teams or personal continuity across inpatient and outpatient mental healthcare? Study protocol for a natural experiment

Impact of the hospital built environment on treatment satisfaction of psychiatric in-patients

BACKGROUND

A hospital built environment can affect patients' treatment satisfaction, which is, in turn, associated with crucial clinical outcomes. However, little research has explored which elements are specifically important for psychiatric in-patients. This study aims to identify which elements of the hospital environment are associated with higher patient satisfaction with psychiatric in-patient care.

METHODS

The study was conducted in Italy and the United Kingdom. Data was collected through hospital visits and patient interviews. All hospitals were assessed for general characteristics, aspects specific to psychiatry (patient safety, mixed/single-sex wards, smoking on/off wards), and quality of hospital environment. Patients' treatment satisfaction was assessed using the Client Assessment of Treatment Scale (CAT). Multi-level modelling was used to explore the role of environment in predicting the CAT scores adjusted for age, gender, education, diagnosis, and formal status.

RESULTS

The study included 18 psychiatric hospitals (7 in Italy and 11 in the United Kingdom) and 2130 patients. Healthcare systems in these countries share key characteristics (e.g. National Health Service, care organised on a geographical basis) and differ in policy regulation and governance. Two elements were associated with higher patient treatment satisfaction: being hospitalised on a mixed-sex ward (p = 0.003) and the availability of rooms to meet family off wards (p = 0.020).

CONCLUSIONS

As hospitals are among the most expensive facilities to build, their design should be guided by research evidence. Two design features can potentially improve patient satisfaction: family rooms off wards and mixed-sex wards. This evidence should be considered when designing or renovating psychiatric facilities.

Behind the screen of voluntary psychiatric hospital admissions: A qualitative exploration of treatment pressures and informal coercion in experiences of patients in Italy, Poland and the United Kingdom

BACKGROUND

Despite the extensive research and intense debate on coercion in psychiatry we have seen in recent years, little is still known about formally voluntarily admitted patients, who experience high levels of perceived coercion during their admission to a psychiatric hospital.

AIMS

The purpose of the present research was to explore forms of treatment pressure put on patients, not only by clinicians, but also by patients' relatives, during admission to psychiatric hospitals in Italy, Poland and the United Kingdom.

METHODS

Data were obtained via in-depth, semi-structured interviews with patients (N = 108) diagnosed with various mental disorders (ICD-10: F20-F49) hospitalised in psychiatric inpatient wards. Maximum variation sampling was applied to ensure the inclusion of patients with different socio-demographic and clinical characteristics. The study applied a common methodology to secure comparability and consistency across participating countries. The qualitative data from each country were transcribed verbatim, coded and subjected to theoretical thematic analysis.

RESULTS

The results of the analysis confirm that the legal classifications of involuntary and voluntary hospitalisation do not capture the fundamental distinctions between patients who are and are not coerced into treatment. Our findings show that the level of perceived coercion in voluntary patients ranges from 'persuasion' and 'interpersonal leverage' (categorised as treatment pressures) to 'threat', 'someone else's decisions' and 'violence' (categorised as informal coercion).

CONCLUSION

We suggest that the term 'treatment pressures' be applied to techniques for convincing patients to follow a suggested course of treatment by offering advice and support in getting professional help, as well as using emotional arguments based on the personal relationship with the patient. In turn, we propose to reserve the term 'informal coercion' to describe practices for pressuring patients into treatment by threatening them, by making them believe that they have no choice, and by taking away their power to make autonomous decisions.

Comparing discrimination among people with schizophrenia, affective and anxiety disorders. A multilevel study in five European countries

BACKGROUND

Most research on mental illness stigma has involved people with psychosis; less information is available for people with affective and anxiety disorders. We aimed to compare experienced and anticipated discrimination among people with schizophrenia, and affective and anxiety disorders.

METHODS

People with schizophrenia (n=773), affective (n=1010) and anxiety disorders (n=372) were recruited during psychiatric admission across 5 EU countries. The Discrimination and Stigma Scale (DISC-12) was used. Multivariate mixed effect logistic regression models with a random effect for hospital and country were performed to explore patient characteristics associated with experienced and anticipated discrimination.

RESULTS

With anxiety disorders, there were more reports of experiences of discrimination in social life (35%), intimate relationships (23.5%), and physical healthcare (19%); in schizophrenia, in relations with neighbours (23.6%) and mental health staff (21.7%); and in affective disorders, in parental role (22.8%). In multivariate analyses, anxiety was associated with increased likelihood of experiencing discrimination in police interactions (OR=1.675; p=0.038) and physical healthcare (OR=1.816; p=0.003), and reduced likelihood when starting a family (OR=0.474; p=0.01) as compared with schizophrenia. Affective (OR=1.367; p=0.004) and anxiety disorders (OR=1.354; p=0.034) were associated with increased likelihood of concealing a diagnosis compared with schizophrenia.

LIMITATIONS

As patients with affective and anxiety disorders were recruited from hospital inpatient units, their experiences may not be representative of all people with these disorders.

CONCLUSIONS

In a sample of people receiving inpatient treatment, experienced and anticipated discrimination are perceived, at least in some life domains, as more of a burden for people with affective and anxiety disorders than those with schizophrenia.

Do outcomes of psychiatric hospital treatment differ for migrants and non-migrants?

PURPOSE

Providing effective treatment for immigrants is an increasing challenge for mental health services across Europe. Yet, little is known as to whether current practice is associated with different outcomes in migrant and non-migrant patients. We compared outcomes of inpatient psychiatric treatment for migrants and non-migrants in a sample from five European countries.

METHODS

Patients with psychotic disorders, affective disorders or anxiety/somatisation disorders admitted to routine psychiatric inpatient treatment were assessed in hospitals in Belgium, Germany, Italy, Poland and the United Kingdom. Treatment outcomes were satisfaction with care during hospitalisation, length of stay, readmission to hospital (any and, specifically, involuntary re-hospitalisation), as well as untoward incidents in a 1-year follow-up period. Outcomes were compared between patients born inside (non-migrants) and outside (migrants) the country of treatment, through mixed regression models.

RESULTS

Across all sites, 985 migrant patients and 6298 non-migrant patients were included. After accounting for the influence of confounding patient characteristics, migrants reported significantly lower treatment satisfaction, but there were no significant differences for length of stay and re-hospitalisations, in general and involuntary ones. Migrants had a lower rate of suicide attempts, but there was no significant difference in other types of untoward incidents in the year following the index admission.

CONCLUSION

The study suggests that migrants are less satisfied with their hospital treatment, there is no evidence that routine inpatient care as currently provided results overall in poorer objective outcomes for migrants than in non-migrant populations.

Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare)

Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.

Patients prefer a continuity model of inpatient psychiatric consultant care: a patient survey in the Louth Mental Health Service

OBJECTIVES

The objective of the paper was to survey patients' preference in relation to a continuity, or split, model of inpatient consultant care in the Louth Mental Health Service.

METHODS

A written survey was administered to all patients attending the Louth Mental Health Service over a 2-week period. Participants were asked for their preferred model of care and clinical information was obtained from their clinical notes.

RESULTS

In total, 149 patients completed the survey questionnaire and 103 respondents (69%) indicated a preference for a continuity model of inpatient consultant psychiatric care. There was a trend for those who reported a past experience of inpatient hospitalisation to indicate a preference for the continuity model (76% v. 61%, respectively, χ2 3.67, p=0.056).

CONCLUSIONS

Patients indicate a preference for a continuity model of inpatient psychiatric care and this is important to consider in service planning. More research is needed to evaluate if any model of consultant care is associated with better patient outcomes.

Personal continuity versus specialisation of care approaches in mental healthcare: experiences of patients and clinicians-results of the qualitative study in five European countries

BACKGROUND

The current debate on organisation of the mental health care raises a question whether to prioritise specialisation of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding specialisation (SC) and personal continuity (PCC) of care in five European countries.

METHODS

Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders (F20-49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and analysed through a thematic analysis method.

RESULTS

Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic relationship and the smooth transition between hospital and community care. Many positive experiences of patients and clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treatment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for coercion, restraint, forced medication or involuntary admission within PCC.

CONCLUSIONS

Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). Therefore, future reforms of mental health services should offer a free choice of either approach, considering that there is no evidence of differences in patient outcomes between PCC and SC approaches.

Use of psychiatric hospitals and social integration of patients with psychiatric disorders: a prospective cohort study in five European countries

PURPOSE

Long lengths of stay (LoS) in psychiatric hospitals or repeated admission may affect the social integration of patients with psychiatric disorders. So far, however, studies have been inconclusive. This study aimed to analyse whether long LoS or repeated admissions in psychiatric wards were associated in different ways with changes in the social integration of patients.

METHODS

Within a prospective cohort study, data were collected on 2181 patients with a main ICD-10 diagnosis of psychotic, affective, or anxiety disorder, hospitalised in the UK, Italy, Germany, Poland, and Belgium in 2015. Social integration was measured at baseline and 1 year after admission using the SIX index, which includes four dimensions: employment, housing, family situation, and friendship. Regression models were performed to test the association between LoS, the number of admissions, and the change in social integration over the study period, controlling for patients' characteristics (trial registration ISRCTN40256812).

RESULTS

A longer LoS was significantly associated with a decrease in social integration (β = - 0.23, 95%CI - 0.32 to - 0.14, p = 0.03), particularly regarding employment (OR = 2.21, 95%CI 1.18-3.24, p = 0.02), housing (OR = 3.45, 95%CI 1.74-5.16, p < 0.001), and family situation (OR = 1.94, 95%CI 1.10-2.78, p = 0.04). In contrast, repeated admissions were only associated with a decrease in friendship contacts (OR = 1.15, 95CI% 1.08-1.22, p = 0.03).

CONCLUSIONS

Results suggest that a longer hospital LoS is more strongly associated with a decrease in patients' social integration than repeated admissions. Special attention should be paid to helping patients to find and retain housing and employment while hospitalised for long periods.

Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) - England and Veneto (Italy) - and three regulated-market systems (RMS) - Germany, Belgium, and Poland -, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients' characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems' complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.

Assessment and Treatment of Patients with Comorbidity of Mental Health Problems and Alcohol Use Disorders: Experiences of Clinicians and Patients in the UK and Poland

AIMS

Treatment of patients with comorbidity of mental health problems and alcohol use disorder (AUD) constitutes a challenge in many countries. The article aimed at exploration of personal experiences of clinicians and patients with the comorbidity regarding its assessment, treatment and organization of care in Poland and the UK.

METHODS

Data were collected via in-depth, semi-structured interviews with clinicians (N = 28) and patients (N = 81) in both countries, according to a unified study protocol. Maximum variation sampling was applied to both study groups. All interviews' transcripts were coded (CAQDA) and the consistency of coding across centres was assessed. Data analysis was performed according to the principles of thematic analysis.

RESULTS

Our data show that most patients with AUD admitted at the psychiatric wards-apart from assessment which is a standard procedure during admission-receive only minimal support during their hospital stay. This is the consequence of two factors: lack of trained staff prepared to help those patients and a priority given to self-referrals by AUD units. At the same time, it is recognized by clinicians and patients that more support is needed to encourage the utilization of AUD services and to prevent the drop-out.

CONCLUSIONS

In order to improve the system response, the use of screening instruments in the process of the assessment of AUD and establishment of special procedures supporting motivation and adherence to treatment and preventing drop-out merits consideration. Moreover, the psychiatric wards and the AUD services could possibly profit from formalization of the collaboration between services.

Predictors of personal continuity of care of patients with severe mental illness: A comparison across five European countries

BACKGROUND

In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country's health system. Since personal continuity would be more suitable for patients with complex psychosocial needs, the aim of this study was to identify predictors of patients' exposure to care approaches in different European countries.

METHODS

Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge, patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients' discharge were assessed in both groups of countries.

RESULTS

Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population.

CONCLUSION

Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless, organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.

The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment

AIMS

A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries.

METHODS

This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812).

RESULTS

We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes.

CONCLUSIONS

Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

Exploring the initial experience of hospitalisation to an acute psychiatric ward

Background

Patient-reported satisfaction with inpatient psychiatric services, within the first few days of admission, is related to positive future outcomes. Despite its predictive value, little is known about this initial experience and what underlies these appraisals. The aim of this study was to qualitatively explore the initial experience of being admitted to an inpatient psychiatric ward.

Methods

Semi-structured interviews were conducted with 61 recently admitted patients across five psychiatric hospitals in London, England. Participants were purposively sampled to ensure a mix of experiences including people with high and low satisfaction scores as measured by the Client Assessment of Treatment. Thematic analysis was used to identify, analyse and report patterns within the data, with content analysis applied to determine whether certain themes were more common to either negative or positive appraisals.

Results

Four broad themes were evident 1) ‘Best place for me right now?’ 2) ‘Different from out in society’ 3) ‘Moving from uncertainty to being informed’ and 4) ‘Relating & Alienating’. Individuals with very positive appraisals spoke most frequently of helpful relationships with both staff and other patients, and feeling cared for. They also spoke of having had previous admissions and the assessment process on entering the ward suggesting that these may be valuable experiences. Conversely, the group with very negative appraisals spoke of relationships that were alienating or where there was a perceived abuse of power. They described restrictions to their freedom, compared hospital to prison and generally had the view that hospital makes you worse.

Conclusions

The experience of hospital within the first few days of admission determines whether an individual has a positive or negative experience of their inpatient care. Reducing the impact of uncertainty and promoting good relationships may help services to improve the initial experience of hospital admission and ultimately improve future outcomes for patients.

Mental health care for adult refugees in high-income countries

Approximately one-third of people who have obtained refugee status live in high-income countries. Over recent years, the number of refugees has been increasing, and there are questions on how many of them need mental health care and which type of interventions are beneficial. Meta-analyses showed highly variable rates of mental disorders in adult refugees. This variability is likely to reflect both real differences between groups and contexts, and methodological inconsistencies across studies. Overall prevalence rates after resettlement are similar to those in host populations. Only post-traumatic stress disorder (PTSD) is more prevalent in refugees. In long-term resettled refugees, rates of anxiety and depressive disorders are higher and linked to poor social integration. Research on mental health care for refugees in high-income countries has been extensive, but often of limited methodological quality and with very context-specific findings. The existing evidence suggests several general principles of good practice: promoting social integration, overcoming barriers to care, facilitating engagement with treatment and, when required, providing specific psychological treatments to deal with traumatic memories. With respect to the treatment of defined disorders, only for the treatment of PTSD there has been substantial refugee-specific research. For other diagnostic categories, the same treatment guidelines apply as to other groups. More systematic research is required to explore how precisely the general principles can be specified and implemented for different groups of refugees and in different societal contexts in host countries, and which specific interventions are beneficial and cost-effective. Such interventions may utilise new communication technologies. Of particular importance are long-term studies to identify when mental health interventions are appropriate and to assess outcomes over several years. Such research would benefit from sufficient funding, wide international collaboration and continuous learning over time and across different refugee groups.

In-patient treatment in functional and sectorised care: patient satisfaction and length of stay

BACKGROUND

Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care.

METHOD

Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812).

RESULTS

In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (β = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (β = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (β = -4.89, 95% CI -13.34 to 3.56, P = 0.26).

CONCLUSIONS

This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.

Predictors of length of stay in psychiatric inpatient units: Does their effect vary across countries?

BACKGROUND

Previous studies in individual countries have identified inconsistent predictors of length of stay (LoS) in psychiatric inpatient units. This may reflect methodological inconsistencies across studies or true differences of predictors. In this study we assessed predictors of LoS in five European countries and explored whether their effect varies across countries.

METHODS

Prospective cohort study. All patients admitted over 14 months to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and United Kingdom were screened. Putative predictors were collected from medical records and in face-to-face interviews and tested for their association with LoS.

RESULTS

Average LoS varied from 17.9days in Italy to 55.1days in Belgium. In the overall sample being homeless, receiving benefits, social isolation, diagnosis of psychosis, greater symptom severity, substance use, history of previous admission and being involuntarily admitted predicted longer LoS. Several predictors showed significant interaction effects with countries in predicting LoS. One variable, homelessness, predicted a different LoS even in opposite directions, whilst for other predictors the direction of the association was the same, but the strength of the association with LoS varied across countries.

CONCLUSIONS

The same patient characteristics have a different impact on LoS in different contexts. Thus, although some predictor variables related to clinical severity and social dysfunction appear of generalisable relevance, national studies on LoS are required to understand the complex influence of different patient characteristics on clinical practice in the given contexts.

Loss of relational continuity of care in schizophrenia: associations with patient satisfaction and quality of care

BACKGROUND

Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact.

AIMS

To examine associations between changes in staff, and patient satisfaction and quality of care.

METHOD

A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder.

RESULTS

Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments.

CONCLUSIONS

Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients.

DECLARATION OF INTEREST

M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.