Delivering a sleep intervention across a youth mental health service using non-expert practitioners: A service evaluation

AIMS

Poor sleep is highly prevalent in young people and increases risk of mental health difficulties, yet access to sleep interventions remains limited. This paper evaluates the use of a sleep intervention delivered by non-expert practitioners in a secondary care youth mental health service.

METHOD

Assistant psychologists were trained to deliver a six-session 1:1 cognitive-behavioural sleep intervention adapted for use with young people with mental health difficulties. A within-subject design assessed clinical outcomes relating to sleep (Insomnia Severity Index), psychological distress and personal goals (Goal Based Outcome Measures) at four time points.

RESULTS

High referral, intervention take-up (82.82%) and completion (70%) rates were reported, together with high baseline levels of insomnia (Insomnia Severity Index mean 20.47, SD 3.68) and poor sleep efficiency (56.36%, SD 17.23). Fifty-six young people (average age 19.2 years, SD 3.25) were included in the outcome analysis. Statistically and clinically significant improvements were seen across all outcome measures, with 68% no longer meeting clinical threshold (ISI ≥15) for insomnia at endpoint.

CONCLUSIONS

This study demonstrates exceptionally high levels of clinical need and engagement with a sleep intervention adapted specifically for young people with mental health difficulties. Whilst limited by the uncontrolled design, large improvements in insomnia and psychological distress support its effectiveness and utility in clinical settings. More robust implementation and evaluation is warranted in broader youth mental health services to promote earlier access.

Doing research in non-specialist mental health services for children and young people: lessons learnt from a process evaluation of the ICALM (Interpersonal Counselling for Adolescent Low Mood) feasibility randomised controlled trial

BACKGROUND

The rising prevalence of adolescent mild depression in the UK and the paucity of evidence-based interventions in non-specialist sectors where most cases present, creates an urgent need for early psychological interventions. Randomised controlled trials (RCTs) are considered the gold standard for obtaining unbiased estimates of intervention effectiveness. However, the complexity of mental health settings poses great challenges for effectiveness evaluations. This paper reports learning from an embedded process evaluation of the ICALM RCT which tested the feasibility of delivering Interpersonal Counselling for Adolescents (IPC-A) plus Treatment as Usual (TAU) versus TAU only for adolescent (age 12-18) mild depression by non-qualified mental health professionals in non-specialist sectors.

METHODS

A qualitative mixed methods process evaluation, drawing on Bronfenbrenner's socioecological model to investigate key influences on trial delivery across macro-(e.g. policy), meso-(e.g. service characteristics) and micro-(e.g. on-site trial processes) contextual levels. Data collection methods included 9 site questionnaires, 4 observations of team meetings, policy documents, and 18 interviews with stakeholders including therapists, heads of service and managers. Thematic analysis focused on understanding how contextual features shaped trial implementation.

RESULTS

The ICALM trial concluded in 2022 having only randomised 14 out of the target 60 young people. At a macro-level, trial delivery was impacted by the COVID-19 pandemic, with services reporting a sharp increase in cases of (social) anxiety over low mood, and backlogs at central referral points which prolonged waiting times for mild cases (e.g. low mood). An interaction between high demand and lack of capacity at a meso-service level led to low prioritisation of trial activities at a micro-level. Unfamiliarity with research processes (e.g. randomisation) and variation in TAU support also accentuated the complexities of conducting an RCT in this setting.

CONCLUSIONS

Conducting a RCT of IPC-A in non-specialist services is not feasible in the current context. Failure to conduct effectiveness trials in this setting has clinical implications, potentially resulting in escalation of mild mental health problems. Research done in this setting should adopt pragmatic and innovative recruitment and engagement approaches (e.g. creating new referral pathways) and consider alternative trial designs, e.g. cluster, stepped-wedge or non-controlled studies using complex systems approaches to embrace contextual complexity.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN82180413. Registered on 31 December 2019.

The Iterative Design and Development of an Affordable Ultrasound Simulator

Simulation-based medical education (SBME) offers a secure and controlled environment for training in ultrasound-related clinical skills such as nerve blocking and intravenous cannulation. Sonographer training for point-of-care ultrasound often adopts the train-the-trainer (TTT) model, wherein a select group of sonographers receive on-site training to subsequently instruct others. This model traditionally relies on expensive commercial ultrasound simulators, which presents a barrier to the scale-up of the TTT model. This study aims to address the need for cost-effective ultrasound simulators suitable for both initial and cascaded TTT. The objective of this report is to present the design and development of an affordable ultrasound simulator, which mimics anatomical features under ultrasound. The simulator was created using additive manufacturing techniques, including 3D printing, ballistic gel, and silicone work. We report on three development-feedback iterations, with feedback provided by an experienced sonographer from FUJIFILM Sonosite Canada Inc. using the think-aloud approach. Overall the results indicate that de-gassed silicone may serve as a good medium; vessels are best produced as hollow canals within the de-gassed silicone; 3D-printed bones cast acoustic shadows, which are reduced by increasing rigidity of the structures, and 3D printing filament and silicone can be used for nerve bundles. Future developments will focus on achieving anatomical accuracy, exploring alternative materials and printing parameters for the bones, and analyzing embedded structures at varying depths within the silicone. The next steps involve integrating the simulator into ultrasound curricula for a formal assessment of its effectiveness as a training tool.

Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective

OBJECTIVE

Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch.

METHOD

In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap.

RESULTS

Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal.

CONCLUSIONS

Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

A child and adult psychiatrist discussion on the development of a youth mental health service

Purpose

Young people can often “fall through the gaps” between Child and Adolescent Mental Health services (CAMHS) and Adult Mental Health services (AMHS). This discursive viewpoint study aims to reflect a conversation among the authors on how CAMHS and AMHS psychiatry came together to develop and embed a UK community “Youth Mental Health Service”.

Design/methodology/approach

This reflective viewpoint study explores the perspectives of three of the lead CAMHS and AMHS psychiatrists from the implementation phase of a community youth mental health service. It explores, in a discursive way, these individuals’ views on some of the key facilitators and barriers in the development of the service that aimed to “bridge the gap” for young people.

Findings

These clinicians’ reflections recognise the importance of strong clinical leadership in enabling a youth/young adult model of mental health to be implemented. They also recognise how culture internal and external to a service has a key role to play in the success and sustainment of implementing an innovative model. This study describes a merging of CAMHS and AMHS psychiatry to meet the needs of young people in the most developmentally appropriate way.

Originality/value

This reflective study highlights the need for services and systems to think creatively about how they can allow flexibility for CAMHS and AMHS psychiatrists to learn and plan together, as well as gain experiences across the age ranges, to facilitate collaborative working that is developmentally appropriate and meets the needs of young people in a way that is accessible to them.

'Very hit and miss': an interpretive phenomenological analysis of ambulance service care for young people experiencing mental health crisis

INTRODUCTION

The ambulance service provides vital front line mental healthcare for young people in crisis, but there is a lack of evidence to guide best practice in this area. The lived experiences of service users can offer important insights to guide service development, therefore we carried out a qualitative evaluation of care provided by the ambulance service to young people experiencing a mental health-related emergency.

METHODS

Ten participants aged 16-25 years who had used the ambulance service due to a mental health crisis within the past 2 years were interviewed about their experiences and view of the care they received. Interviews were transcribed verbatim and interpretative phenomenological analysis used to explore participants' individual narratives and identify recurrent themes.

RESULTS

A theme of inconsistent quality of care was evident in all participants' accounts. Contributing to this superordinate theme were six recurrent themes: positive qualities of individual ambulance clinicians, ambivalence about seeking care, the importance of retaining agency, need for mental health training for ambulance clinicians, need for inter-service collaboration and favourable comparison of the ambulance service to other services.

CONCLUSIONS

We identified some examples of good practice, including person-centred care, respect for patient autonomy and attending to physical health needs. However, our findings suggest the quality of ambulance service mental healthcare is not yet sufficiently consistent. In the absence of mandatory high-quality mental health training and evidence-based protocols, the quality of care appears largely dependent on the qualities and experience of individual ambulance clinicians.

Clinical and cost-effectiveness of social recovery therapy for the prevention and treatment of long-term social disability among young people with emerging severe mental illness (PRODIGY): randomised controlled trial

BACKGROUND

Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention.

AIMS

We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone.

METHOD

A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16-25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation.

RESULTS

We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was -4.44 (95% CI -10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm.

CONCLUSIONS

We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.

Rapid response pathway united to reduce self-harm (RUSH): a case study of a pilot pathway for children and young people

Purpose

In response to elevated local self-harm and suicide rates, and the lack of a dedicated pathway for children and young people (CYP) who self-harm, a rapid response pathway united to reduce self-harm (RUSH) was developed and implemented within Norwich (Norfolk, England). This public health case study aims to describe the pathway model and share its outcomes, learnings, and reflections over the pilot year.

Design/methodology/approach

RUSH was a community-based pilot pathway aiming to support CYP, 11–18 years old, engaging in or at risk of engaging in repeated self-harm and subsequently at risk of repeated attendance at local emergency departments. From May 2020 to April 2021, RUSH supported 61 CYP using funding from NHS England and Improvement.

Findings

This case study shares the pathway’s outcomes, through a mixed-method evaluation. Results indicate statistically significant reductions in self-harm frequency (p = 0.01) and anxiety and depression symptomatology (p < 0.001); a statistically significant increase in progress towards goals (p < 0.001); and a general downward trend in re-attendance at local emergency departments following RUSH. Findings also illustrate high service user satisfaction. Framework analysis of focus group data highlights positive experiences with hope for recommissioning from a staff perspective.

Originality/value

This study will be valuable for services looking to develop and implement a similar service provision, in response to the need to tackle self-harm rates as a broader approach to suicide prevention. In light of the NHS long-term plan (2019), it also serves as an example of how to develop and use a strategic co-production group, and work collaboratively with the voluntary, community and social enterprise sectors.

In vivo coronary artery thrombus imaging with 18F-GP1 PET-CT

Background

Coronary artery thrombus is typically present in type 1 myocardial infarction, but small volumes in the setting of an uncertain culprit lesion may be beyond the detection limit of current imaging modalities.

Purpose

Using a novel glycoprotein IIb/IIIa-receptor radiotracer, 18F-GP1, we investigated whether positron emission tomography-computed tomography (PET-CT) could detect thrombus formation in coronary arteries.

Methods

In a single centre cross-sectional study, patients over 40 years of age with myocardial infarction were recruited after myocardial infarction and underwent underwent CT angiography and 18F-GP1 PET-CT. Stable patients with and without coronary artery disease formed a control cohort. Coronary artery 18F-GP1 uptake was visually assessed and quantified using maximum target-to-background ratios (TBRmax).

Results

Ninety-four (44 post-myocardial infarction and 50 control patients) were included in the cross-sectional analysis. The mean age of the post-myocardial infarction group was 61±9 years, three-quarters were male and two thirds had presented with ST elevation on electrocardiography. 34 (80%) patients post-myocardial infarction, but none of the control patients, demonstrated focal 18F-GP1 uptake in the coronary arteries.

Of 42 vessels with an angiographic culprit lesion, 35 (83%) had 18F-GP1 uptake which was significantly higher than non-culprit vessels (p&lt;0.0001) as well as control vessels (p&lt;0.0001), while non-culprit vessel uptake was similar to control vessel uptake (p=0.567): culprit vessel median TBRmax 1.2 [interquartile range 0.96–1.44], non-culprit vessel TBRmax 0.96 [0.84–1.03] and control vessel TBRmax 0.9 [0.76 to 0.94]. Linear regression models demonstrated univariable associations between coronary 18F-GP1 TBRmax and time from myocardial infarction, male sex and presence of culprit vessel. On multivariable analysis, only culprit vessel status was associated with TBRmax (adjusted R2= 0.22, P&lt;0.001). Based on the Youden's index of the ROC curves, the optimal cut-off of predicting the presence of a culprit vessel was 1.20 with a specificity of 97%, accuracy of 83%, sensitivity (60%) and c-statictic of 0.74.

A patient with ectatic vessel and visual thrombus demonstrated the most intense 18F-GP1 uptake (TBRmax 2.0, highest in the cohort) in the region of heaviest thrombus burden (Figure 2). Extra-coronary uptake was seen in regions of left ventricular thrombus, left atrial appendage thrombus, pulmonary thromboembolism and intramyocardial microvascular obstruction.

Conclusions

18F-GP1 PET-CT is able to detect coronary artery thrombus in culprit lesions following myocardial infarction, as well as extra-coronary thrombotic pathologies that may be important in guiding patient management. 18F-GP1 is highly specific in recognising a culprit lesion from a non-culprit lesion both visually as well as quantitatively.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Figure 1Figure 2

130 Boerhaave’s Syndrome: A Rare Complication of Cannabinoid-Induced Hyperemesis Syndrome

A 22-year-old man was referred to our surgical department with severe central chest pain after a three-day history of &gt; 200 episodes of vomiting a day on a known background of cannabinoid hyperemesis syndrome. A computed tomography (CT) scan showed a ruptured oesophagus and pneumomediastinum, in keeping with Boerhaave’s syndrome. Conservative treatment with keeping the patient nil by mouth and administering intravenous fluids, anti-emetics and broad-spectrum antibiotics was initiated. Follow up CT showed significant reduction in pneumomediastinum. The patient was discharged home 7 days after admission. Spontaneous rupture of the oesophagus is a rare but potentially fatal event. It is caused by an abrupt rise in intra-luminal pressure, usually secondary to forceful vomiting. CT scan should be performed in all suspected cases as the findings dictate management, this being conservative, endoscopic, or surgical. We report on the first published case of Boerhaave’s syndrome as a result of cannabinoid hyperemesis syndrome.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

BACKGROUND

Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings.

METHODS

Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted.

RESULTS

Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation.

CONCLUSIONS

Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges.

KEY PRACTITIONER MESSAGE

Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Editorial Perspective: A call to collective action - improving the implementation of evidence in children and young people's mental health

With growing mental health needs of children and young people and the increasing demand on children and young people's mental health services, narrowing the evidence to practice implementation gap has never been more important. Implementation science and research provides useful theory, identification of barriers and facilitators as well as suggested strategies for improved uptake of evidence-based treatments, but the application of these is often limited. Supporting optimal learning and implementation cultures based on collaborative, relational and pragmatic action planning is likely key. We propose suggested next steps and recommendations to move this agenda forward within the children and young people's mental health field with a 'call to action'. With the need for specific roles and clear accountability, we emphasise that between clinicians, researchers, consumers and policy makers this is everyone's business.

A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocol

BACKGROUND

Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery.

METHODS

The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13-17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a 'healthy living' behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness.

DISCUSSION

UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression.

TRIAL REGISTRATION

ISRCTN, ISRCTN66452702 . Registered 9 April 2020.

Interpersonal counselling for adolescent depression delivered by youth mental health workers without core professional training: a feasibility randomised controlled trial study protocol

BACKGROUND

Depression is a common health problem during adolescence and is associated with adverse academic, social and health outcomes. To meet the demand for treatment for adolescent depression, there is a need for evidence-based interventions suitable for delivery outside of specialist Child and Adolescent Mental Health Services (CAMHS). Interpersonal Counselling for Adolescents (IPC-A) is a brief manualised intervention for adolescent depression suitable for delivery by staff who are not qualified health professionals following participation in a brief training course. While initial piloting within Local Authority services has generated promising results, the effectiveness and cost-effectiveness of IPC-A has yet to be established. This study aims to assess the feasibility of a randomised controlled trial (RCT), evaluating the effectiveness and cost-effectiveness of IPC-A delivered by staff without core professional training in comparison to current provision.

METHOD

Feasibility RCT with process evaluation using ethnographic methodology. Eligible young people (n = 60) will be randomised in a 1:1 ratio to receive either IPC-A or treatment as usual (TAU). Participants will be assessed pre-randomisation (baseline) and followed up at 5, 10 and 23 weeks post-randomisation. A parallel process evaluation will generate understanding of intervention implementation across services and explore the acceptability of the intervention from the perspective of young people and other key stakeholders.

PARTICIPANTS

Young people aged 12-18 years presenting to non-specialist services with symptoms of depression. Youth workers, young people and stakeholders will participate in the process evaluation.

DISCUSSION

The need for effective and accessible interventions for young people with mild/sub-threshold depression who, in most cases, do not meet the threshold for mainstream mental health services is long overdue. The primary output of this feasibility trial will be the design of the subsequent full-scale trial. If the results of the current study indicate that this would be feasible, we intend to progress to a multi-site, assessor-blind, superiority RCT of the effectiveness and cost-effectiveness of IPC-A in comparison to TAU for adolescents presenting to non-specialist services with depressive symptoms. If satisfactory solutions to any problems encountered cannot be identified, alternative research designs will be considered. If proven effective, an IPC-A training programme could be implemented.

TRIAL REGISTRY

ISRCTN registry, ISRCTN82180413 , Registered 31 December 2019.

Practitioner Review: Effectiveness of indicated school-based interventions for adolescent depression and anxiety - a meta-analytic review

BACKGROUND

Interest in delivering psychological interventions within schools to facilitate early intervention is increasing. However, most reviews have focused on universal or preventative programmes rather than interventions designed to decrease existing symptoms of depression or anxiety. This paper aims to provide a meta-analytic review of randomised controlled trials of indicated psychological interventions for young people aged 10-19 with elevated symptoms of depression and/or anxiety.

METHODS

Eight electronic databases were systematically searched from inception to April 2019 for eligible trials. Study quality was assessed using two scales designed to evaluate psychotherapy intervention trials. Random effects meta-analyses were conducted separately for trials that recruited participants based on symptoms of depression and based on symptoms of anxiety.

RESULTS

Data from 45 trials were analysed. Most interventions studied used cognitive and behavioural strategies. Few studies met methodological quality criteria, but effect size was not associated with study quality. Indicated school-based interventions had a small effect on reducing depression symptoms (SMD = .34, 95% CI -0.48, -0.21) and a medium effect on reducing anxiety symptoms (SMD = -.49, 95% CI -0.79, -0.19) immediately postintervention. Subgroup analyses indicated that interventions delivered by internal school staff did not have significant effects on symptoms. Reductions in depression were maintained at short-term (≤6 months) but not medium (>6 months ≤ 12) or long-term (>12-month) follow-up. Reductions in anxiety symptoms were not maintained at any follow-up.

CONCLUSIONS

Indicated school-based interventions are effective at reducing symptoms of depression and anxiety in adolescents immediately postintervention but there is little evidence that these reductions are maintained. Interventions delivered by school staff are not supported by the current evidence base. Further high-quality randomised controlled trials incorporating assessment of longer-term outcomes are needed to justify increased investment in school-based interventions for adolescent depression and anxiety.

The effect of a youth mental health service model on access to secondary mental healthcare for young people aged 14-25 years

Aims and methodThe Norfolk Youth Service was created in 2012 in response to calls to redesign mental health services to better meet the needs of young people. The new service model transcends traditional boundaries by creating a single, 'youth friendly' service for young people aged 14-25 years. The aim of this study was to investigate the effect of the transition to this new model on patterns of referral, acceptance and service use. We analysed routinely collected data on young people aged 14-25 years referred for secondary mental healthcare in Norfolk before and after implementation of the youth mental health service. The number of referrals, their age and gender, proportion of referrals accepted and average number of service contacts per referral by age pre- and post-implementation were compared. RESULTS: Referrals increased by 68% following implementation of the new service model, but the proportion of referrals accepted fell by 27 percentage points. Before implementation of the youth service, there was a clear discrepancy between the peak age of referral and the age of those seen by services. Following implementation, service contacts were more equitable across ages, with no marked discontinuity at age 18 years.Clinical implicationsOur findings suggest that the transformation of services may have succeeded in reducing the 'cliff edge' in access to mental health services at the transition to adulthood. However, the sharp rise in referrals and reduction in the proportion of referrals accepted highlights the importance of considering possible unintended consequences of new service models.Declaration of interestsNone.

The effect of non-pharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials

Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n = 5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d = -0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment.

Young people's experiences of Social Recovery Cognitive Behavioural Therapy and treatment as usual in the PRODIGY trial

AIM

The PRODIGY trial is an ongoing randomized controlled trial of Social Recovery Cognitive Behavioural Therapy (SRCBT), a new intervention designed to improve social functioning in young people at risk of long-term social disability due to severe and complex mental health problems. The aim of this qualitative sub-study was to understand trial participants' experiences of SRCBT and the control condition, treatment as usual.

METHODS

Trial participants were aged 16-25 years with socially disabling severe and complex mental health problems. A purposive sample of trial participants took part in in-depth qualitative interviews which were transcribed verbatim and analysed thematically.

RESULTS

Participants from the SRCBT arm valued the relationship with their therapist, the flexibility of intervention delivery and the cognitive and behavioural techniques taught. They viewed SRCBT as challenging but worthwhile. Participants from the treatment as usual arm reported receiving little support, both prior to and during their participation in the trial. Participants from both arms valued opportunities to talk about their difficulties during trial participation. Increased activity was an important goal of participants from both arms and most expressed high motivation and little hopelessness.

CONCLUSIONS

Currently available services do not meet the needs of some young people with socially disabling mental health problems. Motivation to change appears high at this early stage of disorder, supporting the potential value of intervening early to prevent longer term social disability. SRCBT was well accepted by participants and so is a promising intervention to meet this objective.

Creating an innovative youth mental health service in the United Kingdom: The Norfolk Youth Service

Young people attempting to access mental health services in the United Kingdom often find traditional models of care outdated, rigid, inaccessible and unappealing. Policy recommendations, research and service user opinion suggest that reform is needed to reflect the changing needs of young people. There is significant motivation in the United Kingdom to transform mental health services for young people, and this paper aims to describe the rationale, development and implementation of a novel youth mental health service in the United Kingdom, the Norfolk Youth Service. The Norfolk Youth Service model is described as a service model case study. The service rationale, national and local drivers, principles, aims, model, research priorities and future directions are reported. The Norfolk Youth Service is an innovative example of mental health transformation in the United Kingdom, comprising a pragmatic, assertive and "youth-friendly" service for young people aged 14 to 25 that transcends traditional service boundaries. The service was developed in collaboration with young people and partnership agencies and is based on an engaging and inclusive ethos. The service is a social-recovery oriented, evidence-based and aims to satisfy recent policy guidance. The redesign and transformation of youth mental health services in the United Kingdom is long overdue. The Norfolk Youth Service represents an example of reform that aims to meet the developmental and transitional needs of young people at the same time as remaining youth-oriented.

Participation in developing youth mental health services: “Cinderella service” to service re-design

Purpose

Whilst there are pockets of excellence in the provision of Child and Adolescent Mental Health Services (CAMHS), many services fail to meet young people’s needs. Considering this, the purpose of this paper is to ascertain perceptions of CAMHS provision in a rural county of the UK to inform re-design of youth mental health services.

Design/methodology/approach

The study comprised of two phases: phase one involved analysis of questionnaire data of youth views of CAMHS. Phase two involved analysis of the “Have Your Say” event data which explored perceptions of CAMHS and future service re-design. Data were thematically analysed.

Findings

Knowledge of the existence and purpose of CAMHS was variable. Participants wanted accessible information about services, rights, confidentiality and for this to be provided in multiple media. Young people wanted staff who were easy to talk to, genuine, understanding and who valued their insights. Participants wanted to be offered choice about appointments, location and timing. An ideal mental health service was described as a “one-stop-shop” of co-locality and multi-agency collaboration. Young people clearly expressed a desire to influence the design and delivery of the radical service re-design and to be embedded in its development.

Practical implications

The results highlighted multiple problems with CAMHS provision and provided a clear justification for the re-design of services.

Originality/value

This was a novel approach demonstrating the importance, utility and power of effective participatory practices for informing the re-design of services.

Maximizing the Adjacent Possible in Automata Chemistries

Automata chemistries are good vehicles for experimentation in open-ended evolution, but they are by necessity complex systems whose low-level properties require careful design. To aid the process of designing automata chemistries, we develop an abstract model that classifies the features of a chemistry from a physical (bottom up) perspective and from a biological (top down) perspective. There are two levels: things that can evolve, and things that cannot. We equate the evolving level with biology and the non-evolving level with physics. We design our initial organisms in the biology, so they can evolve. We design the physics to facilitate evolvable biologies. This architecture leads to a set of design principles that should be observed when creating an instantiation of the architecture. These principles are Everything Evolves, Everything's Soft, and Everything Dies. To evaluate these ideas, we present experiments in the recently developed Stringmol automata chemistry. We examine the properties of Stringmol with respect to the principles, and so demonstrate the usefulness of the principles in designing automata chemistries.

The Hidradenitis Suppurativa Priority Setting Partnership

BACKGROUND

Hidradenitis suppurativa (HS) has been neglected by medical researchers and society in general, despite being a relatively common, painful, chronic skin disease.

OBJECTIVES

To generate a top 10 list of HS research priorities, from the perspectives of patients with HS, carers and clinicians, to take to funding bodies.

METHODS

A priority setting partnership was established between patients with HS, carers and clinicians, following the James Lind Alliance process. Survey 1 requested submission of HS uncertainties, which were grouped into 'indicative uncertainties' for prioritization in survey 2. The 30 highest-ranked indicative uncertainties were reduced to a 'top 10' list using nominal group technique at a prioritization workshop attended by all relevant HS stakeholders.

RESULTS

In total 1495 potential uncertainties were submitted in survey 1, including 57% from patients with HS and carers, and grouped into 55 indicative uncertainties. Ranking in survey 2 was completed by 371 participants, 50% of whom were patients and carers. The final workshop was attended by 22 HS stakeholders and four facilitators and produced a top 10 list, the three highest priorities in descending order being (i) What is the most effective and safe group of oral treatments in treating HS? (ii) What is the best management of an acute flare? (iii)What is the impact of HS and its treatment on people with HS?

CONCLUSIONS

The top 10 HS research priorities have been directly disseminated to funders to raise awareness of HS. The next step is to generate research questions that will provide the evidence needed to improve care for patients with HS.

Realizing nursing: a multimodal biopsychopharmacosocial approach to psychiatric nursing

The biological and psychosocial components of health, illness and treatment are well recognized. In addition, pharmacological interventions interact with both these components regarding health and illness; all components are potentially modifiable. A better understanding of these interactions on the course of illness, especially at the interface between illness and treatment, is needed to guide effective clinical and psychiatric nursing interventions. To this end, a multimodal biopsychopharmacosocial approach to assessment, formulation, care planning and implementation by psychiatric nurses is proposed. It is argued that a biopsychopharmacosocial approach, including a multimodal functional element, provides a person-centred, responsive and responsible basis for a comprehensive approach to practice. The use of this approach will improve intervention outcomes and contribute to the ongoing development of psychiatric nursing practice. It is suggested that, in part, this will be achieved through innovative teaching methods delivered by 'expert nurses' and clinical academics.

Fixation failure in an isolated tibial eminence ACL traction avulsion fracture in a paratrooper: is there an association with vitamin D deficiency?

Tibial eminence avulsion fracture at the ACL footprint may be caused by high-energy forces such as a fall, in which the ACL ligament proves stronger than the forces that hold the bone together. For reasons of bone maturity however, tibial spine avulsion fractures where the ACL remains intact, typically occur in children but are rare in adults. This case demonstrates a rare type of adult tibial avulsion fracture with intact ACL and subsequent fragment fixation failure in which vitamin D deficiency may have been contributory. Because there is a high rate of inadequate vitamin D levels in patients undergoing orthopaedic surgery and a known impact on bone healing complications, post-operative bone fixation failure may also occur. This case report may therefore prompt further awareness for considering pre-surgical vitamin D deficiency screening in adults presenting with rare avulsion fractures, and may further demonstrate its impact on surgical outcomes.

Evidence for linkage of migraine in Rolandic epilepsy to known 1q23 FHM2 and novel 17q22 genetic loci

Migraine headaches are a common comorbidity in Rolandic epilepsy (RE) and familial aggregation of migraine in RE families suggests a genetic basis not mediated by seizures. We performed a genome-wide linkage analysis of the migraine phenotype in 38 families with RE to localize potential genetic contribution, with a follow-up in an additional 21 families at linked loci. We used two-point and multipoint LOD (logarithm of the odds) score methods for linkage, maximized over genetic models. We found evidence of linkage to migraine at chromosome 17q12-22 [multipoint HLOD (heterogeneity LOD) 4.40, recessive, 99% penetrance], replicated in the second dataset (HLOD 2.61), and suggestive evidence at 1q23.1-23.2, centering over the FHM2 locus (two-point LOD 3.00 and MP HLOD 2.52). Sanger sequencing in 14 migraine-affected individuals found no coding mutations in the FHM2 gene ATP1A2. There was no evidence of pleiotropy for migraine and either reading or speech disorder, or the electroencephalographic endophenotype of RE when the affected definition was redefined as those with migraine or the comorbid phenotype, and pedigrees were reanalyzed for linkage. In summary, we report a novel migraine susceptibility locus at 17q12-22, and a second locus that may contribute to migraine in the general population at 1q23.1-23.2. Comorbid migraine in RE appears genetically influenced, but we did not obtain evidence that the identified susceptibility loci are consistent with pleiotropic effects on other comorbidities in RE. Loci identified here should be fine-mapped in individuals from RE families with migraine, and prioritized for analysis in other types of epilepsy-associated migraine.

Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?

This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.

SU-D-BRCD-06: Measurement of Elekta Electron Energy Spectra Using a Small Magnetic Spectrometer

PURPOSE

To demonstrate how a small magnetic spectrometer can measure the energy spectra of seven electron beams on an Elekta Infinity tuned to match beams on a previously commissioned machine.

METHODS

Energyspectra were determined from measurements of intensity profiles on 6″-long computed radiographic (CR) strips after deflecting a narrow incident beam using a small (28 lbs.), permanent magnetic spectrometer. CR plateexposures (<1cGy) required special beam reduction techniques and bremsstrahlung shielding. Curves of CR intensity (corrected for non- linearity and background) versus position were transformed into energy spectra using the transformation from position (x) on the CR plate to energy (E) based on the Lorentz force law. The effective magnetic field and its effective edge, parameters in the transformation, were obtained by fitting a plot of most probable incident energy (determined from practical range) to the peak position.

RESULTS

The calibration curve (E vs. x) fit gave 0.423 Tesla for the effective magnetic field. Most resulting energy spectra were characterized by a single, asymmetric peak with peak position and FWHM increasing monotonically with beam energy. Only the 9-MeV spectrum was atypical, possibly indicating suboptimal beam tuning. These results compared well with energy spectra independently determined by adjusting each spectrum until the EGSnrc Monte Carlo calculated percent depth-dose curve agreed well with the corresponding measured curve.

CONCLUSIONS

Results indicate that this spectrometer and methodology could be useful for measuring energy spectra of clinical electron beams at isocenter. Future work will (1) remove the small effect of the detector response function (due to pinhole size and incident angular spread) from the energy spectra, (2) extract the energy spectra exiting the accelerator from current results, (3) use the spectrometer to compare energy spectra of matched beams among our clinical sites, and (4) modify the spectrometer to utilize radiochromic film.

In vitro and in vivo characterization of PF-04418948, a novel, potent and selective prostaglandin EP₂ receptor antagonist

BACKGROUND AND PURPOSE

Studies of the role of the prostaglandin EP(2) receptor) have been limited by the availability of potent and selective antagonist tools. Here we describe the in vitro/in vivo pharmacological characterization of a novel EP(2) receptor antagonist, PF-04418948 (1-(4-fluorobenzoyl)-3-{[(6-methoxy-2-naphthyl)oxy]methyl} azetidine-3-carboxylic acid).

EXPERIMENTAL APPROACH

Functional antagonist potency was assessed in cell-based systems expressing human EP(2) receptors and native tissue preparations from human, dog and mouse. The selectivity of PF-04418948 was assessed against related receptors and a panel of GPCRs, ion channels and enzymes. The ability of PF-04418948 to pharmacologically block EP(2) receptor function in vivo was tested in rats.

KEY RESULTS

PF-04418948 inhibited prostaglandin E(2)(PGE(2))-induced increase in cAMP in cells expressing EP(2) receptors with a functional K(B) value of 1.8 nM. In human myometrium, PF-04418948 produced a parallel, rightward shift of the butaprost-induced inhibition of the contractions induced by electrical field stimulation with an apparent K(B) of 5.4 nM. In dog bronchiole and mouse trachea, PF-04418948 produced parallel rightward shifts of the PGE(2)-induced relaxation curve with a K(B) of 2.5 nM and an apparent K(B) of 1.3 nM respectively. Reversal of the PGE(2)-induced relaxation in the mouse trachea by PF-04418948 produced an IC(50) value of 2.7 nM. Given orally, PF-04418948 attenuated the butaprost-induced cutaneous blood flow response in rats. PF-04418948 was selective for EP(2) receptors over homologous and unrelated receptors, enzymes and channels.

CONCLUSIONS AND IMPLICATIONS

PF-04418948 is an orally active, potent and selective surmountable EP(2) receptor antagonist that should aid further elaboration of EP(2) receptor function.

Continuum-level modelling of cellular adhesion and matrix production in aggregates

Key regulators in tissue-engineering processes such as cell culture and cellular organisation are the cell-cell and cell-matrix interactions. As mathematical models are increasingly applied to investigate biological phenomena in the biomedical field, it is important, for some applications, that these models incorporate an adequate description of cell adhesion. This study describes the development of a continuum model that represents a cell-in-gel culture system used in bone-tissue engineering, namely that of a cell aggregate embedded in a hydrogel. Cell adhesion is modelled through the use of non-local (integral) terms in the partial differential equations. The simulation results demonstrate that the effects of cell-cell and cell-matrix adhesion are particularly important for the survival and growth of the cell population and the production of extracellular matrix by the cells, concurring with experimental observations in the literature.

Guerrillero Heroico--a lasting impression

What once was simply a cultural tradition is fast becoming a popular phenomenon amongst Western tourists. Temporary henna tattoo designs performed by street or beach vendors are prevalent throughout the Middle East and Asia, particularly in holiday resorts. The public may be mistaken in thinking that the fashionable trend comes without significant risk. The main ingredient in the temporary tattooing method is henna (Lawsonia inermis), a flowering plant with dyeing properties that takes only several hours to be absorbed but provides an effect lasting around ten to fifteen days on the recipient's skin. The side effects of henna tattoos are well documented in the literature, although it is not clear whether the side effects directly relate to the henna ingredient or the additives used to prolong the designs. The most commonly noted complications include allergic contact dermatitis, infection, hypertrophic and keloid scarring and temporary or permanent hypo- or hyperpigmentation. In very rare cases, type 1 hypersensitivity reactions (angioedema and anaphylaxis) have been reported. The following case report highlights several of these complications and the relevant management.

Supplementation with whole cottonseed causes long-term reduction of methane emissions from lactating dairy cows offered a forage and cereal grain diet

The objective of our work was to supplement a forage and cereal diet of lactating dairy cows with whole cottonseed (WCS) for 12 wk and to determine whether the expected reduction in CH(4) would persist. A secondary objective was to determine the effect of supplementing the diet with WCS on milk yield and rumen function over the 12-wk feeding period. Fifty lactating cows were randomly allocated to 1 of 2 diets (control or WCS). The 2 separate groups were each offered, on average, 4.2 kg of DM/cow per day of alfalfa hay (a.m.) and 6.6 kg of DM/cow per day of ryegrass silage (p.m.) on the ground in bare paddocks each day for 12 wk. Cows in each group were also individually offered dietary supplements for 12 wk in a feed trough at milking times of 5.4 kg of DM/cow per day of cracked wheat grain and 0.5 kg of DM/cow per day of cottonseed meal (control) or 2.8 kg of DM/cow per day of cracked wheat grain and 2.61 kg of DM/cow per day of WCS. The 2 diets were formulated to be similar in their concentrations of CP and ME, but the WCS diet was designed to have a higher fat concentration. Samples of rumen fluid were collected per fistula from the rumen approximately 4 h after grain feeding in the morning. Samples were taken from 8 cows (4 cows/diet) on 2 consecutive days in wk 2 of the covariate and wk 3, 6, 10, and 12 of treatment and analyzed for volatile fatty acids, ammonia-N, methanogens, and protozoa. The reduction in CH(4) emissions (g/d) because of WCS supplementation increased from 13% in wk 3 to 23% in wk 12 of treatment. Similarly, the reduction in CH(4) emissions (g/kg of DMI) increased from 5.1% in wk 3 to 14.5% in wk 12 of treatment. It was calculated that the average reduction in CH(4) emissions over the 12-wk period was 2.9% less CH(4) per 1% added fat, increasing from 1.5% in wk 3 to 4.4% less CH(4) in wk 12. There was no effect of WCS supplementation on rumen ammonia-N, rumen volatile fatty acids, rumen methanogens, and rumen protozoa. On average over the 12-wk period, supplementation with WCS decreased the yield of milk (10%), fat (11%), protein (14%), lactose (11%), and fat plus protein (12%) and BW gain (31%). The WCS supplementation had no effect on milk fat concentration but resulted in a decrease in concentration of protein (5%) and lactose (11%). The major finding from this study is that addition of WCS to the diet of lactating dairy cows resulted in a persistent reduction in CH(4) emissions (g of CH(4)/kg of DMI) over a 12-wk period and that these reductions in CH(4) are consistent with previous work that has studied the addition of oilseeds to ruminant diets.

imProving Outcomes after STroke clinical pilot trial protocol

RATIONALE

One in three patients experience depression after stroke and this risk is consistent over time. A strategy to prevent depression that could be economically delivered to most stroke patients and ideally which also has a low likelihood of adverse events needs to be developed and evaluated. Aims POST aims to determine whether a simple intervention (postcards) prevents depression (Hospital Anxiety and Depression rating Scale, HADS depression subscale score > or =8) in patients with a recent stroke. Secondary end-points include reduced anxiety (HADS anxiety subscale score > or =8) and improved health-related quality of life in patients with a recent stroke.

DESIGN

A single-centre randomised, double-blind, pilot trial to prevent depression in patients with a recent (within 8 weeks) stroke presenting to hospital. Patients will be enrolled over 12 months and randomised to receive three trial-specific assessments (baseline, 3- and 6-month assessments of mood, HRQoL and social functioning), or three trial-specific assessments plus a postcard sent centrally in a sealed envelope at 1, 2, 3, 4 and 5 months after discharge from hospital. Blinded follow-up telephone assessments will be conducted for both groups. STUDY OUTCOMES AND SAMPLE SIZE: For the primary end-point the POST trial will have 80% power to detect a relative risk of 0.4 given an incidence of depression of 30%. For the secondary aims POST has 90% power to detect a difference of 3 points on the HADS depression subscale (assuming a standard deviation of 6 points) between randomised groups. This includes an inflation factor of 15% to account for patients lost to follow-up.

DISCUSSION

Evidence of efficacy will determine whether a multi-centre, international trial is warranted.

Zoning: focused support: a trust wide implementation project

Applying pragmatic risk management procedures to facilitate the sharing of clinical knowledge in and across mental health teams. Abstract Zoning: focused support is pragmatic risk management support procedure that enhances adherence to operational policies, provides a forum in which staff can receive support and visually facilitates the sharing of clinical knowledge. This paper presents a 3-year multi-method management project that sought to introduce zoning principles into all teams of an inner city Mental Health NHS Trust. By changing the language and culture of the organization findings indicate that there has been a positive attitudinal shift in how the approach is perceived. It is considered to be of value to staff, service users and their families and 73% of teams are now using it routinely.