Empowering School Staff to Support Pupil Mental Health Through a Brief, Interactive Web-Based Training Program: Mixed Methods Study

BACKGROUND

Schools in the United Kingdom and elsewhere are expected to protect and promote pupil mental health. However, many school staff members do not feel confident in identifying and responding to pupil mental health difficulties and report wanting additional training in this area.

OBJECTIVE

We aimed to explore the feasibility of Kognito's At-Risk for Elementary School Educators, a brief, interactive web-based training program that uses a simulation-based approach to improve school staff's knowledge and skills in supporting pupil mental health.

METHODS

We conducted a mixed methods, nonrandomized feasibility study of At-Risk for Elementary School Educators in 6 UK primary schools. Our outcomes were (1) school staff's self-efficacy and preparedness to identify and respond to pupil mental health difficulties, (2) school staff's identification of mental health difficulties and increased risk of mental health difficulties, (3) mental health support for identified pupils (including conversations about concerns, documentation of concerns, in-class and in-school support, and referral and access to specialist mental health services), and (4) the acceptability and practicality of the training. We assessed these outcomes using a series of questionnaires completed at baseline (T1), 1 week after the training (T2), and 3 months after the training (T3), as well as semistructured qualitative interviews. Following guidance for feasibility studies, we assessed quantitative outcomes across time points by comparing medians and IQRs and analyzed qualitative data using reflexive thematic analysis.

RESULTS

A total of 108 teachers and teaching assistants (TAs) completed T1 questionnaires, 89 (82.4%) completed T2 questionnaires, and 70 (64.8%) completed T3 questionnaires; 54 (50%) completed all 3. Eight school staff members, including teachers, TAs, mental health leads, and senior leaders, participated in the interviews. School staff reported greater confidence and preparedness in identifying and responding to mental health difficulties after completing the training. The proportion of pupils whom they identified as having mental health difficulties or increased risk declined slightly over time (medianT1=10%; medianT2=10%; medianT3=7.4%), but findings suggested a slight increase in accuracy compared with a validated screening measure (the Strengths and Difficulties Questionnaire). In-school mental health support outcomes for identified pupils improved after the training, with increases in formal documentation and communication of concerns as well as provision of in-class and in-school support. Referrals and access to external mental health services remained constant. The qualitative findings indicated that school staff perceived the training as useful, practical, and acceptable.

CONCLUSIONS

The findings suggest that brief, interactive web-based training programs such as At-Risk for Elementary School Educators are a feasible means to improve the identification of and response to mental health difficulties in UK primary schools. Such training may help address the high prevalence of mental health difficulties in this age group by helping facilitate access to care and support.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Access to and perceived unmet need for mental health services and support in a community sample of UK adolescents with and without experience of childhood adversity

AIMS

Children and adolescents with a history of adverse childhood experiences (ACEs) are more likely than their peers to develop mental health difficulties, but not enough is known about their help-seeking behaviours and preferences. We aimed to determine whether ACEs are associated with access to and perceived unmet need for mental health services and support amongst secondary school students.

METHODS

We used multi-level logistic regression with data from the 2020 OxWell Student Survey to assess whether ACEs were associated with (1) prior access to mental health support and (2) perceived unmet need for mental health services in a community sample of English secondary school students. We assessed ACEs as a cumulative score from the Center for Youth Wellness Adverse Childhood Experiences Questionnaire: Teen Self-Report version and accounted for current mental health difficulties as measured by the 25-item Revised Children's Anxiety and Depression Scale (RCADS).

RESULTS

Our analysis included 2018 students across 64 schools, of whom 29.9% (598/2002) reported prior access to mental health support. Of those not reporting prior access, 34.1% (469/1377) reported a perceived unmet need for services. In the unadjusted models, cumulative ACE scores were significantly positively associated with both prior access to mental health support (odds ratio (OR) = 1.36; 95% confidence interval (CI): 1.29-1.43) and perceived unmet need for mental health services (OR = 1.47; 95% CI: 1.37-1.59), meaning that students who had experienced adversity had a greater chance of having previously accessed support as well as perceiving an unmet need for services. After adjusting for mental health difficulties and other sociodemographic variables, cumulative ACE scores were positively associated with prior access (adjusted OR (aOR) = 1.25; 95% CI: 1.17-1.34 with a significant interaction between RCADS and ACE scores, aOR = 0.88; 95% CI: 0.84-0.93) as well as perceived unmet need (aOR = 1.32; 95% CI: 1.21-1.43 with a significant interaction between RCADS and ACE scores, aOR = 0.85; 95% CI: 0.78-0.91).

CONCLUSIONS

Although it is encouraging that adolescents with experience of adversity are more likely than their peers with similar levels of depression and anxiety symptoms to have accessed mental health support, there remains a concern that those who have not accessed support are more likely to perceive an as-yet unmet need for it. Mental health support must be available, accessible and acceptable to all who need it, especially for those groups that traditionally have not accessed services, including the more marginalised and vulnerable populations.

Current evidence and opportunities in child and adolescent public mental health: a research review

BACKGROUND

A public mental health lens is increasingly required to better understand the complex and multifactorial influences of interpersonal, community and institutional systems on the mental health of children and adolescents.

METHODS

This research review (1) provides an overview of public mental health and proposes a new interactional schema that can guide research and practice, (2) summarises recent evidence on public mental health interventions for children and adolescents, (3) highlights current challenges for this population that might benefit from additional attention and (4) discusses methodological and conceptual hurdles and proposes potential solutions.

RESULTS

In our evidence review, a broad range of universal, selective and indicated interventions with a variety of targets, mechanisms and settings were identified, some of which (most notably parenting programmes and various school-based interventions) have demonstrated small-to-modest positive effects. Few, however, have achieved sustained mental health improvements.

CONCLUSIONS

There is an opportunity to re-think how public mental health interventions are designed, evaluated and implemented. Deliberate design, encompassing careful consideration of the aims and population-level impacts of interventions, complemented by measurement that embraces complexity through more in-depth characterisation, or 'phenotyping', of interpersonal and environmental elements is needed. Opportunities to improve child and adolescent mental health outcomes are gaining unprecedented momentum. Innovative new methodology, heightened public awareness, institutional interest and supportive funding can enable enhanced study of public mental health that does not shy away from complexity.

Stratification of adolescents across mental phenomena emphasizes the importance of transdiagnostic distress: a replication in two general population cohorts

Characterizing patterns of mental phenomena in epidemiological studies of adolescents can provide insight into the latent organization of psychiatric disorders. This avoids the biases of chronicity and selection inherent in clinical samples, guides models of shared aetiology within psychiatric disorders and informs the development and implementation of interventions. We applied Gaussian mixture modelling to measures of mental phenomena from two general population cohorts: the Avon Longitudinal Study of Parents and Children (ALSPAC, n = 3018) and the Neuroscience in Psychiatry Network (NSPN, n = 2023). We defined classes according to their patterns of both positive (e.g. wellbeing and self-esteem) and negative (e.g. depression, anxiety, and psychotic experiences) phenomena. Subsequently, we characterized classes by considering the distribution of diagnoses and sex split across classes. Four well-separated classes were identified within each cohort. Classes primarily differed by overall severity of transdiagnostic distress rather than particular patterns of phenomena akin to diagnoses. Further, as overall severity of distress increased, so did within-class variability, the proportion of individuals with operational psychiatric diagnoses. These results suggest that classes of mental phenomena in the general population of adolescents may not be the same as those found in clinical samples. Classes differentiated only by overall severity support the existence of a general, transdiagnostic mental distress factor and have important implications for intervention.

Partnerships at the Interface of Education and Mental Health Services: The Utilisation and Acceptability of the Provision of Specialist Liaison and Teacher Skills Training

Partnerships between school staff and mental health professionals have the potential to improve access to mental health support for students, but uncertainty remains regarding whether and how they work in practice. We report on two pilot projects aimed at understanding the implementation drivers of tailored strategies for supporting and engaging front-line school staff in student mental health. The first project provided regular, accessible mental health professionals with whom school staff could meet and discuss individual or systemic mental health concerns (a school 'InReach' service), and the other offered a short skills training programme on commonly used psychotherapeutic techniques (the School Mental Health Toolbox; SMHT). The findings from the activity of 15 InReach workers over 3 years and 105 individuals who attended the SMHT training demonstrate that school staff made good use of these services. The InReach workers reported more than 1200 activities in schools (notably in providing specialist advice and support, especially for anxiety and emotional difficulties), whilst most SMHT training attendees reported the utilisation of the tools (in particular, supporting better sleep and relaxation techniques). The measures of acceptability and the possible impacts of the two services were also positive. These pilot studies suggest that investment into partnerships at the interface of education and mental health services can improve the availability of mental health support to students.

Leveraging Administrative Data to Better Understand and Address Child Maltreatment: A Scoping Review of Data Linkage Studies

BACKGROUND

This scoping review aimed to overview studies that used administrative data linkage in the context of child maltreatment to improve our understanding of the value that data linkage may confer for policy, practice, and research.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, and ERIC electronic databases in June 2019 and May 2020 for studies that linked two or more datasets (at least one of which was administrative in nature) to study child maltreatment. We report findings with numerical and narrative summary.

RESULTS

We included 121 studies, mainly from the United States or Australia and published in the past decade. Data came primarily from social services and health sectors, and linkage processes and data quality were often not described in sufficient detail to align with current reporting guidelines. Most studies were descriptive in nature and research questions addressed fell under eight themes: descriptive epidemiology, risk factors, outcomes, intergenerational transmission, predictive modelling, intervention/service evaluation, multi-sector involvement, and methodological considerations/advancements.

CONCLUSIONS

Included studies demonstrated the wide variety of ways in which data linkage can contribute to the public health response to child maltreatment. However, how research using linked data can be translated into effective service development and monitoring, or targeting of interventions, is underexplored in terms of privacy protection, ethics and governance, data quality, and evidence of effectiveness.

Determinants of patient-reported outcome trajectories and symptomatic recovery in Improving Access to Psychological Therapies (IAPT) services

BACKGROUND

Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.

METHODS

Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.

RESULTS

Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).

CONCLUSIONS

We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients' needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

Determining stakeholder priorities and core components for school-based identification of mental health difficulties: A Delphi study

Only approximately half of children and young people (CYP) with mental health difficulties access mental health services in England, with under-identification of need as a contributing factor. Schools may be an ideal setting for identifying mental health difficulties in CYP, but uncertainty remains about the processes by which these needs can best be identified and addressed. In this study, we conducted a two-round, three-panel Delphi study with parents, school staff, mental health practitioners, and researchers to inform the development of a program to identify mental health difficulties in primary schools. We aimed to assess and build consensus regarding (a) the aims of such a program, (b) identification model preferences, (c) key features of the identification model, and (d) key features of the implementation model. A total of 54 and 42 participants completed the Round 1 and 2 questionnaires, respectively. In general, responses indicated that all three panels supported the idea of school-based identification of mental health difficulties. Overall, 53 of a possible 99 items met the criteria for inclusion as program core components. Five main priorities emerged, including that (a) the program should identify children experiencing mental health difficulties across the continuum of severity, as well as children exposed to adversity, who are at greater risk of mental health difficulties; (b) the program should train staff and educate pupils about mental health in parallel; (c) parental consent should be obtained on an opt-out basis; (d) the program must include clear mechanisms for connecting identified pupils to care and support; and (e) to maximize implementation success, the program needs to lie within a school culture that values mental health and wellbeing. In highlighting these priorities, our study provides needed stakeholder consensus to guide further development and evaluation of mental health interventions within schools.

Study protocol: the OxWell school survey investigating social, emotional and behavioural factors associated with mental health and well-being

INTRODUCTION

Improving our understanding of the broad range of social, emotional and behavioural factors that contribute to mental health outcomes in adolescents will be greatly enhanced with diverse, representative population samples. We present a protocol for a repeated self-report survey assessing risk and protective factors for mental health and well-being in school pupils aged 8-18 years with different socioeconomic backgrounds in England. The survey will provide a comprehensive picture of mental health and associated risks at the community level to inform the development of primary and secondary prevention and treatment strategies in schools.

METHODS AND ANALYSIS

This protocol is for a large-scale online repeated self-report survey, representative of children and adolescents aged 8-18 years attending schools or further education colleges in participating counties in England. The survey consists of around 300 questions, including validated measures of mental health and well-being, risk and protective factors, and care-seeking behaviour and preferences. Additional questions each year vary to address current events and novel hypotheses, developed by the research team, collaborators and stakeholders. Primary analyses will investigate current and changing risk and protective factors, care-seeking behaviour and attitudes to allowing linkage of their sensitive data to other databases for research, and will compare measures of mental health to measures of well-being.

ETHICS AND DISSEMINATION

The study was approved by the University of Oxford Research Ethics Committee (Reference: R62366). Tailored data summaries will be provided to participating schools and stakeholders within 3 months of data collection. The main findings will be presented at scientific meetings, published in peer-reviewed journals and shared via digital and social media channels. At the end of the study, other researchers will be able to apply for access to anonymous data extracts.

COVID-19 partial school closures and mental health problems: A cross-sectional survey of 11,000 adolescents to determine those most at risk

Background

Understanding adolescents' mental health during lockdown and identifying those most at risk is an urgent public health challenge. This study surveyed school pupils across Southern England during the first COVID‐19 school lockdown to investigate situational factors associated with mental health difficulties and how they relate to pupils' access to in‐school educational provision.

Methods

A total of 11,765 pupils in years 8–13 completed a survey in June–July 2020, including questions on mental health, risk indicators and access to school provision. Pupils at home were compared to those accessing in‐school provision on risk and contextual factors and mental health outcomes. Multilevel logistic regression analyses compared the effect of eight risk and contextual factors, including access to in‐school provision, on depression, anxiety and self‐reported deterioration in mental wellbeing.

Results

Females, pupils who had experienced food poverty and those who had previously accessed mental health support were at greatest risk of depression, anxiety and a deterioration in wellbeing. Pupils whose parents were going out to work and those preparing for national examinations in the subsequent school year were also at increased risk. Pupils accessing in‐school provision had poorer mental health, but this was accounted for by the background risk and contextual factors assessed, in line with the allocation of in‐school places to more vulnerable pupils.

Conclusions

Although the strongest associations with poor mental health during school closures were established risk factors, further contextual factors of particular relevance during lockdown had negative impacts on wellbeing. Identifying those pupils at greatest risk for poor outcomes is critical for ensuring that appropriate educational and social support can be given to pupils either at home or in‐school during subsequent lockdowns.

Feasibility of School-Based Identification of Children and Adolescents Experiencing, or At-risk of Developing, Mental Health Difficulties: a Systematic Review

Under-identification of mental health difficulties (MHD) in children and young people contributes to the significant unmet need for mental health care. School-based programmes have the potential to improve identification rates. This systematic review aimed to determine the feasibility of various models of school-based identification of MHD. We conducted systematic searches in Medline, Embase, PsycINFO, ERIC, British Education Index, and ASSIA using terms for mental health combined with terms for school-based identification. We included studies that assessed feasibility of school-based identification of students in formal education aged 3-18 with MHD, symptomatology of MHD, or exposed to risks for MHD. Feasibility was defined in terms of (1) intervention fit, (2) cost and resource implications, (3) intervention complexity, flexibility, manualisation, and time concerns, and (4) adverse events. Thirty-three studies met inclusion criteria. The majority focused on behavioural and socioemotional problems or suicide risk, examined universal screening models, and used cross-sectional designs. In general, school-based programmes for identifying MHD aligned with schools' priorities, but their appropriateness for students varied by condition. Time, resource, and cost concerns were the most common barriers to feasibility across models and conditions. The evidence base regarding feasibility is limited, and study heterogeneity prohibits definitive conclusions about the feasibility of different identification models. Education, health, and government agencies must determine how to allocate available resources to make the widespread adoption of school-based identification programmes more feasible. Furthermore, the definition and measurement of feasibility must be standardised to promote any future comparison between models and conditions.

REACT study protocol: resilience after the COVID-19 threat (REACT) in adolescents

INTRODUCTION

COVID-19-related social isolation and stress may have significant mental health effects, including post-traumatic stress, anxiety and depression. These factors are thought to disproportionately affect populations at risk of psychopathology, such as adolescents with a history of childhood adversity (CA). Therefore, examining which factors may buffer the impact of COVID-19-related stress and isolation in vulnerable adolescents is critical. The Resilience After the COVID-19 Threat (REACT) study assesses whether emotion regulation capacity, inflammation and neuroimmune responses to stress induced in the laboratory prior to the pandemic predict responses to COVID-19-related social isolation and stress in adolescents with CA. We aim to elucidate the mechanisms that enable vulnerable adolescents to maintain or regain good mental health when confronted with COVID-19.

METHODS AND ANALYSIS

We recruited 79 adolescents aged 16-26 with CA experiences from the Resilience After Individual Stress Exposure study in which we assessed emotion regulation, neural and immune stress responses to an acute stress task. Our sample completed questionnaires at the start of the UK lockdown ('baseline'; April 2020) and three (July 2020) and 6 months later (October 2020) providing crucial longitudinal information across phases of the pandemic progression and government response. The questionnaires assess (1) mental health, (2) number and severity of life events, (3) physical health, (4) stress perception and (5) loneliness and friendship support. We will use multilevel modelling to examine whether individual differences at baseline are associated with responses to COVID-19-related social isolation and stress.

ETHICS AND DISSEMINATION

This study has been approved by the Cambridge Psychology Research Ethics Committee (PRE.2020.037). Results of the REACT study will be disseminated in publications in scientific peer-reviewed journals, presentations at scientific conferences and meetings, publications and presentations for the general public, and through social media.

Establishing a Theory-Based Multi-Level Approach for Primary Prevention of Mental Disorders in Young People

The increasing prevalence of mental health disorders and psychosocial distress among young people exceeds the capacity of mental health services. Social and systemic factors determine mental health as much as individual factors. To determine how best to address multi-level risk factors, we must first understand the distribution of risk. Previously, we have used psychometric methods applied to two epidemiologically-principled samples of people aged 14-24 to establish a robust, latent common mental distress (CMD) factor of depression and anxiety normally distributed across the population. This was linearly associated with suicidal thoughts and non-suicidal self-harm such that effective interventions to reduce CMD across the whole population could have a greater total benefit than those that focus on the minority with the most severe scores. In a randomised trial of mindfulness interventions in university students (the Mindful Student Study), we demonstrated a population-shift effect whereby the intervention group appeared resilient to a universal stressor. Given these findings, and in light of the COVID-19 pandemic, we argue that population-based interventions to reduce CMD are urgently required. To target all types of mental health determinants, these interventions must be multi-level. Careful design and evaluation, interdisciplinary work, and extensive local stakeholder involvement are crucial for these interventions to be effective.

Psychological interventions for people with psychotic experiences: A systematic review and meta-analysis of controlled and uncontrolled effectiveness and economic studies

OBJECTIVE

Many people with psychotic experiences do not develop psychotic disorders, yet those who seek help demonstrate high clinical complexity and poor outcomes. In this systematic review and meta-analysis, we evaluated the effectiveness and cost-effectiveness of psychological interventions for people with psychotic experiences.

METHOD

We searched 13 databases for studies of psychological interventions for adults with psychotic experiences, but not psychotic disorders. Our outcomes were the proportion of participants remitting from psychotic experiences (primary); changes in positive and negative psychotic symptoms, depression, anxiety, functioning, distress, and quality of life; and economic outcomes (secondary). We analysed results using multilevel random-effects meta-analysis and narrative synthesis.

RESULTS

A total of 27 reports met inclusion criteria. In general, there was no strong evidence for the superiority of any one intervention. Five studies reported on our primary outcome, though only two reports provided randomised controlled trial evidence that psychological intervention (specifically, cognitive behavioural therapy) promoted remission from psychotic experiences. For secondary outcomes, we could only meta-analyse trials of cognitive behavioural therapy. We found that cognitive behavioural therapy was more effective than treatment as usual for reducing distress (pooled standardised mean difference: -0.24; 95% confidence interval = [-0.37, -0.10]), but no more effective than the control treatment for improving any other outcome. Individual reports indicated that cognitive behavioural therapy, mindfulness-based cognitive therapy, sleep cognitive behavioural therapy, systemic therapy, cognitive remediation therapy, and supportive treatments improved at least one clinical or functional outcome. Four reports included economic evaluations, which suggested cognitive behavioural therapy may be cost-effective compared with treatment as usual.

CONCLUSION

Our meta-analytic findings were primarily null, with the exception that cognitive behavioural therapy may reduce the distress associated with psychotic experiences. Our analyses were limited by scarcity of studies, small samples and variable study quality. Several intervention frameworks showed preliminary evidence of positive outcomes; however, the paucity of consistent evidence for clinical and functional improvement highlights a need for further research into psychological treatments for psychotic experiences.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42016033869.

Revisiting CAPE-P15 cut-off values to increase sensitivity for detecting psychotic experiences in primary care

Psychotic experiences (PE) co-occur with depression and anxiety, and indicate severity of general mental distress. Identifying PE in primary care mental health settings may facilitate access to evidence-based interventions. The Community Assessment of Psychic Experiences - Positive 15-items Scale (CAPE-P15) has shown promise in detecting those at ultra-high risk of developing psychosis. Based on a sample of 1131 individuals with common mental disorder we propose high-sensitivity thresholds of the CAPE-P15 to broaden its application across clinical settings.

Identifying key targets for interventions to improve psychological wellbeing: replicable results from four UK cohorts

BACKGROUND

An increasing importance is being placed on mental health and wellbeing at individual and population levels. While there are several interventions that have been proposed to improve wellbeing, more evidence is needed to understand which aspects of wellbeing are most influential. This study aimed to identify key items that signal improvement of mental health and wellbeing.

METHODS

Using network analysis, we identified the most central items in the graph network estimated from the well-established Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Results were compared across four major UK cohorts comprising a total of 47,578 individuals: the Neuroscience in Psychiatry Network, the Scottish Schools Adolescent Lifestyle and Substance Use Survey, the Northern Ireland Health Survey, and the National Child Development Study.

RESULTS

Regardless of gender, the three items most central in the network were related to positive self-perception and mood: 'I have been feeling good about myself'; 'I have been feeling confident'; and 'I have been feeling cheerful'. Results were consistent across all four cohorts.

CONCLUSIONS

Positive self-perception and positive mood are central to psychological wellbeing. Psychotherapeutic and public mental health interventions might best promote psychological wellbeing by prioritising the improvement of self-esteem, self-confidence and cheerfulness. However, empirical testing of interventions using these key targets is needed.

Psychological interventions for people with psychotic experiences: protocol for a systematic review and meta-analysis

BACKGROUND

Many people who have common mental disorders, such as depression and anxiety, also have some psychotic experiences. These experiences are associated with higher clinical complexity, poor treatment response, and negative clinical outcomes. Psychological interventions have the potential to improve outcomes for people with psychotic experiences. The aims of this systematic review are to (1) synthesise the evidence on the effectiveness and cost-effectiveness of psychological interventions to reduce psychotic experiences and their associated distress and (2) identify key components of effective interventions.

METHODS

Our search strategy will combine terms for (1) psychological interventions, (2) psychotic experiences, and (3) symptoms associated with psychotic experiences. We will search the following online databases: MEDLINE, Embase, PsycINFO, all Cochrane databases, British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium (HMIC), Education Resources Information Center (ERIC), and EconLit. Our primary outcome is the proportion of people who recovered or remitted from psychotic experiences after the intervention. Our secondary outcomes are changes in positive psychotic symptoms, negative psychotic symptoms, depression, anxiety, functioning (including social, occupational, and academic), quality of life, and cost-effectiveness. Two independent reviewers will judge each study against pre-specified inclusion and exclusion criteria and will extract study characteristics, outcome data, and intervention components. Risk of bias and methodological quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and the Drummond Checklist. Results will be synthesised using random-effects meta-analysis and narrative synthesis.

DISCUSSION

The identification of effective psychological interventions and of specific components associated with intervention effectiveness will augment existing evidence that can inform the development of a new, tailored intervention to improve outcomes related to psychotic symptoms, anxiety and depression, distress, functioning, and quality of life.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033869.

A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties

BACKGROUND

Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.

METHOD

Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3-18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.

RESULTS

We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.

CONCLUSIONS

Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.

Acceptability of screening for mental health difficulties in primary schools: a survey of UK parents

BACKGROUND

Many children and young people experiencing mental health difficulties (MHD) do not access care, often due to inadequate identification. Schools have a unique potential to improve early identification; however, evidence is limited regarding the acceptability of school-based identification programmes. This study aimed to examine parents' beliefs about the acceptability of school-wide MHD screening in primary schools.

METHODS

We collaborated with experts in school-based mental health to develop a questionnaire to measure parental attitudes toward school-wide MHD screening. The questionnaire contained 13 items relating to acceptability; three open-text boxes for comments on harms, benefits, and screening in general; and four questions that captured demographic information. Parents of children attending four primary schools in Cambridgeshire and Norfolk completed the questionnaire. We calculated counts, percentages, and means for each statement, and analysed responses to open-ended questions using content analysis.

RESULTS

Two hundred ninety parents returned the questionnaire across the four schools (61% response rate). In the 260 questionnaires analysed, a total of 254 parents (98%) believed that it is important to identify MHD early in life, and 251 (97%) believed that schools have an important role in promoting pupils' emotional health. The majority of parents (N = 213; 82%) thought that screening would be helpful, although 34 parents (13%) thought that screening would be harmful. Perceived harms of screening included inaccurate identification, stigmatisation, and low availability of follow-up care. There was no clear consensus regarding how to obtain consent or provide feedback of screening results. There were no significant differences in responses according to ethnicity, gender, age, or school.

CONCLUSIONS

Results suggest that most parents within the socio-demographic context of our study will accept MHD screening within primary schools, and that school-based screening is viable from the perspective of parents. The comments provided about potential harms as well as suggestions for programme delivery are relevant to inform the development and evaluation of acceptable and sustainable school-based identification models. Implementation and scale-up of such programmes will require further understanding of the perspectives of mental health professionals, school staff, and the general public as well as further evaluation against the established standards for identification programmes.

Coproducing healthcare service improvement for people with common mental health disorders including psychotic experiences: a study protocol of a multiperspective qualitative study

INTRODUCTION

Some people, who have common mental health disorders such as depression and anxiety, also have some psychotic experiences. These individuals may experience a treatment gap: their symptoms neither reach the increasingly high threshold for secondary care, nor do they receive full benefit from current interventions offered by the Improving Access to Psychological Therapies (IAPT) programme. The result may be poorer clinical and functional outcomes. A new talking therapy could potentially benefit this group. Informed by principles of coproduction, this study will seek the views of service users and staff to inform the design and development of such a therapy.

METHODS AND ANALYSIS

Semistructured interviews will be conducted with IAPT service users, therapists and managers based in three different geographical areas in England. Our sample will include (1) approximately 15 service users who will be receiving therapy or will have completed therapy at the time of recruitment, (2) approximately 15 service users who initiated treatment but withdrew, (3) approximately 15 therapists each with at least 4-month experience in a step-3 IAPT setting and (4) three IAPT managers. Data analysis will be based on the constant comparative method.

ETHICS AND DISSEMINATION

The study has been approved by the London Harrow Research Ethics Committee (reference: 18/LO/0642), and all National Health Service Trusts have granted permissions to conduct the study. Findings will be published in peer-reviewed academic journals, and presented at academic conferences. We will also produce a 'digest' summary of the findings, which will be accessible, visual and freely available.

Macroscopic Rotator Cuff Tendinopathy and Histopathology Do Not Predict Repair Outcomes of Rotator Cuff Tears

BACKGROUND

Numerous studies have identified factors that may affect the chances of rotator cuff healing after surgery. Intraoperative tendon quality may be used to predict healing and to determine type of repair and/or consideration of augmentation. There are no data that correlate how gross tendon morphology and degree of tendinopathy affect patient outcome or postoperative tendon healing. Purpose/Hypothesis: The purposes of this study were to (1) compare the gross appearance of the tendon edge during arthroscopic rotator cuff repair with its histological degree of tendinopathy and (2) determine if gross appearance correlated with postoperative repair integrity. The hypothesis was that gross (macroscopic) tendon with normal thickness, no delamination, and elastic tissue before repair would have a correlation with low Bonar scores, higher postoperative American Shoulder and Elbow Surgeons (ASES) scores, and increased rates of postoperative tendon healing on ultrasound.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 105 patients undergoing repair of medium-size (1-3 cm) full-thickness rotator cuff tears were enrolled in the study. Intraoperatively, the supraspinatus tendon was rated on thickness, fraying, and stiffness. Tendon tissue was recovered for histological analysis based on the Bonar scoring system. Postoperative ASES and ultrasound assessment of healing were obtained 1 year after repair. Correlation between gross appearance of the tendon and rotator cuff histology was determined.

RESULTS

Of the 105 patients, 85 were followed the study to completion. The mean age of the patients was 61.6 years; Bonar score, 7.5; preoperative ASES score, 49; and postoperative ASES score, 86. Ninety-one percent of repairs were intact on ultrasound. Gross appearance of torn rotator cuff tendon tissue did not correlate with histological appearance. Neither histological (Bonar) score nor gross appearance correlated with multivariate analysis of ASES score, postoperative repair status, or demographic data.

CONCLUSION

The degree of tendinopathy did not correlate with morphological appearance of the tendon. Neither of these parameters correlated with healing or patient outcome. This study suggests that the degree of tendinopathy, unlike muscle atrophy, may not be predictive of outcomes and that, on appearance, poor quality tendon has adequate healing capacity. Therefore, abnormal gross tendon appearance should not affect the repair effort or technique.

First-time rhesus monkey mothers, and mothers of sons, preferentially engage in face-to-face interactions with their infants

Face-to-face interactions between mothers and infants occur in both human and non-human primates, but there is large variability in the occurrence of these behaviors and the reason for this variability remains largely unexplored. Other types of maternal investment have been shown to be dependent on infant sex (e.g. milk production and maternal responsiveness) and maternal experience (e.g. symmetrical communication). Thus, we sought to determine whether variability in face-to-face interactions, that is, mutual gazing (MG), which are hypothesized to be important for later socio-cognitive development, could be explained by these variables. We studied 28 semi-free ranging rhesus monkey (Macaca mulatta) mother-infant dyads (6 primiparous; 12 male infants) born and reared at the Laboratory of Comparative Ethology field station at the NIH Animal Center in Poolesville, MD, across the first 90 postnatal days. Infant sex (i.e. male) was a significant predictor of maternal grooming (β ± SE = 0.359 ± 0.164, Z = 2.19, P = 0.029) whereas both parity (i.e. first time mothers) and infant sex (i.e. male) significantly predicted MG (parity: β ± SE = -0.735 ± 0.223, Z = -3.30, P < 0.001; infant sex: β ± SE = 0.436 ± 0.201, Z = 2.17, P = 0.029). Separation from the mother (outside of arm's reach) was not influenced by parity or infant sex. Together with existing literature, these findings point toward differential maternal investment for sons versus daughters. Mothers may be investing differentially in sons, behaviorally, to ensure their future social competence and thus later reproductive success. Collectively, our findings add to the literature that is beginning to identify early life experiences that may lead to sex differences in neurological and behavioral development.