BMC Psychiatry

PurposeImproved access to care, particularly primary care, is a key goal of healthcare reform proposals. Individuals with severe psychiatric illness have high rates of emergency room use rather than primary/preventive care. Massachusetts implemented health care reform in 2006 intended to provide more individuals with health care insurance and, thereby, access to primary care. To our knowledge no study has assessed whether this legislation impacted barriers to primary care access among individuals with serious mental illness. MethodsThis study looked at effects of the 2006 Massachusetts legislation among individuals being hospitalized at a large psychiatric hospital drawing patients from throughout Eastern Massachusetts. A retrospective review of records noted whether a primary care physician was identified, along with demographic and clinical characteristics for each patient. ResultsPrimary care affiliation was significantly lower in 2008 than 2005. Affiliation increased 9 years after legislation, though not to the levels of the year prior to the legislation. Risk ratios for PCP non-affiliation were similar whether the model controlled for demographic characteristics only; primary and drug and alcohol related diagnoses in addition to demographic characteristics; or insurance type in addition to demographic characteristics and diagnoses. ConclusionsThe risk of being unaffiliated with a PCP 2 years after legislative reform was nearly 20% higher than 1 year before. Our findings are concerning in that patients at this large regional psychiatry hospital may have been receiving less primary/preventive care in 2008 than in 2005, despite legislation aimed at improving primary care access for the general population.

ObjectivesCognitive behaviour therapy for psychosis (CBTp) should be delivered in psychiatric inpatient settings, yet little is known about therapists perspectives on delivering it. This study examined therapists perspectives on delivering a crisis-focused CBTp-informed (cCBTp) intervention. DesignThe study was part of the CRISIS (CRISis cbtp in Inpatient Settings) study, a feasibility randomised controlled trial of the cCBTp intervention for inpatients experiencing psychosis. A mixed methods approach combined therapy log data and qualitative interviews with therapists after the trial therapy was complete. MethodsSeven CRISIS study therapists completed a therapy log, which we analysed descriptively. Semi-structured interviews with six of these therapists explored their experiences with intervention training and delivery, which was analysed using thematic analysis. ResultsThe results from the therapy log demonstrated that therapists undertook a comprehensive assessment and prioritised engagement with all participants, and most developed a formulation, which informed change strategy delivery aligned with the patients goals. In the qualitative interviews, therapists emphasised the importance of delivering culturally competent flexible, person-centred therapy and supporting patients to work towards goals such as coping with the crisis and discharge planning. They described challenges of delivering therapy in the acute crisis context including interruptions to therapy sessions, patients experiencing acute symptoms, and environment restrictions. ConclusionsThe study demonstrated the importance of delivering cCBTp collaboratively and supporting patients in understanding and managing their own crisis. It also identified several challenges therapists had delivering the therapy. Further research is needed to explore therapists experiences of delivering psychological interventions in this setting. Practitioner Points1. Therapists must be flexible in their approach and remain adaptable with session timing, location and content to accommodate disruptions in inpatient settings, ensuring continuity of therapy despite high levels of distress and non-attendance. 2. A validating, therapeutic relationship is central to support patients with psychosis in crisis, enabling trust, safety and effective goal-directed work. 3. Therapists and patients collaboratively developing a crisis-focused formulation helps patients make sense of their current crisis, facilitates empowerment and enhances relapse prevention and discharge planning. 4. Therapist should actively explore and integrate patients cultural experiences including experiences of racism into therapy to help strengthen engagement and provide a holistic understanding of a patients experiences.

BackgroundThe Dynamic Sustainability Framework emphasizes the need for improving programs after implementation in response to the evolving environment. This report illustrates said framework and describes significant changes made to the Psychiatric Day Hospital (DH) at North York General Hospital (NYGH) in response to pandemic-related changes in participant demographic. Patient and staff satisfaction pre- and post-program modification are compared. ProblemThe COVID-19 pandemic resulted in increased DH referral acuity and patient affect dysregulation. The program needed to adapt to these changes and better serve the new DH patient population. MethodsDH participants and team member feedback was gathered. Five major areas of improvement were identified. Changes were systematically introduced from July 2021 to January 2022. Feedback post-implementation in 2022-2023 from patients and DH team members were gathered for comparison. InterventionsDialectical Behavioral Therapy (DBT) was adopted as the theoretical basis of the revamped Day Hospital Program. All Day Hospital staff underwent training in DBT skills, with the creation of new treatment schedules and materials. Two separate streams were created for differing patient illness severity. The program continued to run during implementation of new changes, without disruption to the existing clinical workload. ResultsThe program transitioned from a 3-week psychoeducational and rudimentary CBT program to a dual-stream 4-week DBT-based program to address patient acuity and higher prevalence of emotional dysregulation. Quantitative and qualitative feedback from new program participants have been positive. ConclusionsThe Day Hospital Program at NYGH made a successful transition in response to an evolving healthcare landscape.

BackgroundBipolar disorder and anxiety disorders are two prominent mental disorders that represent a significant global health challenge. ObjectiveThe Global Burden of Disease Study 2021 (GBD 2021) was employed to evaluate sex differences in the incidence of bipolar disorder (BD) and anxiety disorder (ANX) globally by year, age, and socioeconomic status. MethodWe estimated sex-specific incidence of BD and ANX from GBD 2021 globally and in 204 countries and territories from 1990 to 2021. The sociodemographic index (SDI) was used to gauge national socioeconomic development and the Health Organization (WHO) region was used as a division of regions. Differences in age-standardized incidence rates (ASRs) by sex (absolute and relative) and risk ratios (95% confidence interval) were calculated annually and by age. Annual percent change (APC) was calculated by joinpoint regression modeling and linear regression analyses were performed to explore the socioeconomic factors associated with sex differences in incidence. ResultsThe absolute and relative sex difference in ASRs of BD showed a slight declining trend during 1990 and 2021, with absolute difference decreasing from 2.50 to 1.83, and relative difference decreasing from 1.08 to 1.06; The absolute and relative sex difference in ASRs of ANX showed an increasing trend during 1990 and 2021, with absolute difference increasing from 170.02 to 208.08, and relative difference increasing from 1.35 to 1.36. Worldwide, females had a higher risk of BD and ANX than males in 1990and 2021. The highest Risk ratios of BD and ANX were observed in the European Region in 2021.The greatest relative sex difference of BD was 1.09 in the age group of 30-34. The greatest relative difference of ANX was 1.51 in the age group of 20-24. Relative sex differences of BD and ANX were significantly and positively correlated with SDI (BD, standardized {beta} = 0.27 (95% CI, 0.22 to 0.33), P < 0.001; ANX, standardized {beta} = 0.80 (95% CI, 0.47 to 1.14), P < 0.001). ConclusionsSex difference in the incidence of anxiety disorders and bipolar disorder have persisted worldwide over the past several decades, and the rates have consistently been higher among females than males. The sex difference in the global incidence of bipolar disorder has shown a slight improvement, but that in the global incidence of anxiety disorders has not been effectively mitigated. The sex difference is even more pronounced at younger ages and in more developed nations. The findings emphasize the significance of sex-specific health policies to reduce sex differences in the incidence of bipolar and anxiety disorders.

Interprofessional collaboration is critical for integrated psychiatric care, yet few studies have profiled clinicians readiness for interprofessional learning and team climate across professions while adjusting for demographic and experiential factors. We conducted a single-site cross-sectional survey of physicians, nursing staff, and allied health professionals in a specialist psychiatric hospital in Japan. Primary outcomes were the Readiness for Interprofessional Learning Scale-Professional version (RIPLS-Pro) total score and the Participative Safety subscale of the Team Climate Inventory. We compared professions and clinical settings using regression models adjusted for age and years of practice and analyzed free-text responses using directed content analysis. Profession was associated with both RIPLS-Pro and Participative Safety scores: allied health staff scored the highest, followed by physicians and nursing staff. Clinical setting and the profession-by-setting interaction did not explain additional variance. Age correlated positively with RIPLS-Pro scores. Qualitative data highlighted cross-cutting barriers (time pressure, fragmented handovers, role ambiguity) and pragmatic enablers (brief protected huddles, shared handover templates, clearer task ownership). Overall, variability in interprofessional readiness and psychological safety appeared to be driven more by profession-linked working conditions and organization-wide routines than by ward or unit type. Small-scale, locally adapted quality improvement efforts that protect routine interprofessional touchpoints, standardize handovers, and clarify role ownership warrant prospective evaluation to strengthen collaborative practice in psychiatric care.

Open-door policies in inpatient psychiatric care have been increasingly adopted to enhance patient autonomy and reduce coercive practices. However, systematic methodologies for evaluating patient experiences in these settings remain limited. This study applies Patient Journey Mapping within an open-door acute psychiatric unit, to comprehensively analyze the hospitalization experience. Using a mixed-methods approach, qualitative data were first collected via focus groups (n=18), adhering GRAMMS guidelines, to identify critical touchpoints, and then quantitative data (n=32) were gathered through an adapted Likert-type ordinal scale to assess patient satisfaction. Data were analyzed using content analysis methodology. Results delineate key hospitalization phases and identify "Moments of Truth," "Moments of Pain," and "Wow Moments," which significantly shape patients perceptions of care quality. While open-door policies promote autonomy and reduce psychological distress, challenges persist in admission processes, medication administration privacy, and communication regarding structured activities. These findings highlight the need for patient-centered methodologies in psychiatric care to optimize service delivery, foster therapeutic environments, and enhance recovery-oriented practices.

IntroductionAntipsychotic medications are used to treat individuals with severe mental illness (SMI), but are associated with rapid weight gain and several physical and mental risk factors. Early, proactive weight management is necessary to pre-empt these risk factors. The aim was to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help to manage antipsychotic-induced weight gain. MethodsRealist review to identify contextual factors and underlying mechanisms associated with effective, non-pharmacological weight management interventions for adults > 18 years old. Practitioners and lived experience stakeholders were integral. Results74 documents used to construct programme theory and 12 testable context-mechanism-outcome configurations. People with SMI benefit from support when navigating interventions aimed at managing the weight gain. From a practitioner perspective, a good therapeutic relationship is important in helping people with SMI navigate early diagnosis and treatment options and facilitating exploring any pre-existing issues. Interventions that are flexible and tailored to the needs of individuals, ideally starting early in a persons recovery journey are likely to yield better results. Additional sources of support include family, friends and peers with lived experience who can help individuals transition to autonomous goal-setting. The review findings also emphasise the significant effect of stigma/dual stigma on individuals with SMI and weight gain. ConclusionsSuccessful interventions are collaborative, flexible and underpinned by early and comprehensive assessment with use of appropriate behaviour change approaches. The therapeutic relationship is key with a de-stigmatising approach required. A realist evaluation with primary data is currently underway. Practitioner PointsO_LIIndividuals with severe mental illness on antipsychotic medications are at high risk for rapid weight gain and associated adverse mental and physical outcomes. C_LIO_LIEarly comprehensive assessment by knowledgeable, respectful practitioners promotes therapeutic relationship development and identification of individuals specific risk factors and support, such as pre-existing disordered eating behaviours and the presence of family/carer and peer support. C_LIO_LICase management or care coordination needs to be strengthened to ensure individuals access to consistent primary and secondary services, as well as community-based services. C_LI

IntroductionHere, we aimed to evaluate primary prescription nonadherence post-discharge from an acute inpatient psychiatric unit. Prescription nonadherence is a concern across all patient care settings, with primary nonadherence defined as not picking up prescribed medication from the pharmacy or not delivering prescriptions to the pharmacy. Secondary nonadherence, defined as filling a prescription but not taking the medication as prescribed, was not tracked in this study. The incidence of nonadherence can vary widely across settings and has been reported to range from 3- 86%. This is a particular concern in patients with a primary psychiatric diagnosis both in an outpatient and inpatient setting. DesignThe prescription fill rate of eligible patients was tracked on days 7 and 21 post-discharge from acute inpatient psychiatric units of an acute care multispecialty urban community teaching hospital. ResultsIn total, 72 patients aged 18 and above (44%, women) were analyzed. A primary nonadherence incidence of 43% was found, which did not vary significantly across the analyzed variables of age, sex, or primary diagnosis. ConclusionPrimary nonadherence is a significant issue in this population. Strategies, such as the implementation of "med-to-bed" programs and use of longer acting injectables when appropriate, would help in increasing adherence. Further research, including the evaluation of other variables that affect nonadherence, is needed to identify and develop steps to overcome the obstacles to adherence.

First-hand experience with psychedelics may help clinicians develop skills and knowledge needed to work with the profound changes to conscious awareness occasioned by psychedelics. However, the topic remains contentious and underexplored. In this world-first study, we investigated the utility of psilocybin experiential therapist training in a sample of 14 mental healthcare professionals training to provide psilocybin-assisted therapy. Participants received one 25 mg dose of psilocybin in a clinical research context alongside psychological support before, during, and after dosing. Quantitative measures and semi-structured interviews were then undertaken by participants to explore their experiences and reflections. Through the intervention, participants reported developing a greater and embodied understanding of key therapeutic principles and processes. Moreover, they reported increases in therapeutic qualities (e.g., empathy, attunement, emotion regulation) that underpin therapeutic alliance and promote trust and safety. While participants did not report experiencing harms from participation, they speculated about two potential risks of psychedelic experiential therapist training: first, that it could elicit challenging material that feels destabilising for a period; and second, that therapists could project their experience onto clients in a manner that narrows interpretative range and reduces attunement. Recommendations were made for psychedelic experiential therapist training design and implementation, including strategies to mitigate such risks. Participants indicated that psychedelic experiential therapist training is necessary but not sufficient for providing the highest quality of care in psychedelic-assisted therapy. Findings support the inclusion of an optional psychedelic experiential component within psychedelic therapist training programs for clinicians with prior psychotherapeutic training and well-developed reflective capacity.

BackgroundEarly access to services is essential for those suffering a psychotic illness or at risk for the condition. Lack of knowledge of services and public stigma are major barriers to care and are associated with increased duration of untreated psychosis and delays in those at clinical high-risk for psychosis (CHR-P) from accessing support. Education and contact programmes have shown promise in reducing stigmatizing views, however, few have been co-produced and delivered by service users and clinical staff. A three-hour co-produced educational workshop was developed and delivered by service users and Outreach and Support in South London (OASIS) staff. The aim was to assess the feasibility of delivering a co-produced workshop to youth community workers, to see if it improved knowledge of psychosis, attitudes to mental health services and reduced stigma towards people with psychosis as well as seeing if the workshop increased community referrals to OASIS. MethodEducational workshops were developed by community stakeholders and service users. Pre- and post-workshop questionnaires assessed knowledge of psychosis, attitudes towards mental health teams and stigma towards individuals with a psychotic disorder. Participants and service users views on the workshop were explored through two focus groups. Results9 workshops were delivered to 75 community participants. Following the workshop participants questionnaire scores showed improvements in knowledge of psychosis, improved attitudes towards mental health teams and a reduction in stigmatizing views towards people with psychosis. The workshop was overwhelmingly well received with 97% agreeing with the statement that they learnt something valuable from the workshop. Referrals to the OASIS service increased by 22% following the workshops. ConclusionThe co-produced educational workshop designed and delivered by service users and OASIS staff was successful in improving participants knowledge, attitudes and reducing stigma. We observed an increase in the rate of referrals to the OASIS service, although it is difficult to whether this was due to the workshops or to other outreach activities. Future research should examine whether these effects are long-lasting and explore online delivered workshops to reach more participants in the wider community.

IntroductionObesity is a significant public health issue in the United States (U.S.), with rates of obesity increasing for the past few years, particularly in Hispanics. Individuals with schizophrenia have additional risks for obesity due to the metabolic burden associated with antipsychotic (AP) medications, limited physical activity due to negative symptoms, and poor eating habits. There are no published studies that have compared obesity rates between Hispanics and non-Hispanics with first episode psychosis (FEP). We aimed to explore the relationship between ethnicity and obesity in FEP patients prior to the initiation of AP treatment, to eliminate the potential effects of AP treatment on weight. MethodsBaseline data from 145 individuals with FEP enrolled in a FEP research study was used. Demographic, education, occupation and Body Mass Index (BMI) data for FEP participants was stratified by ethnicity (Hispanic vs. non-Hispanic) and BMI (< 25 or [&ge;] 25). Variables with a p-value < 0.1 were entered into a multivariate linear regression model using a manual backwards elimination approach, using BMI as a continuous measure as the outcome and ethnicity as our predictor of interest. ResultsTwenty-four Hispanics, and 121 non-Hispanics were included. Baseline characteristics were not significantly different between ethnicity groups, except for BMI which was significantly higher in Hispanics (mean = 25.3, SD = 6.0, p = 0.037) than non-Hispanics (mean = 23.0, SD = 4.5). Data stratified by BMI showed that age, ethnicity, mothers occupation, and socioeconomic status (SES) were associated with BMI. Multivariate linear regression showed that Hispanic ethnicity (B = 3.04, SE = 1.32, p = 0.024) and age (B = 0.36, SE = 0.09, p < 0.001) were statistically significantly associated with higher BMI scores while adjusting for sex (B = - 0.67, SE = 1.04, p = 0.521). DiscussionHispanic individuals with FEP present with higher BMI scores compared to non-Hispanics, even before the initiation of antipsychotic treatment. Therefore, in addition to exercise and healthy eating habits, the use of AP medications with less metabolic burden is advisable along with using the lowest effective dose.

BackgroundInvolving service users in decisions about their care is essential to delivering recovery-orientated mental health services. Research shows, however, that service users often are not involved in the assessment and management of the risk component of their care. This paper explores mental health professionals perceptions of the barriers and enablers to shared decision-making in risk assessment and management. MethodsWe conducted semilJstructured interviews with fifteen mental health professionals working within either a community mental health or an early intervention service in the United Kingdom. Data collection and analysis were guided by the Theoretical Domains Framework for behaviour change, which encompasses fourteen domains identified as influencing behaviour. ResultsThe findings show that staff are motivated to work collaboratively but experience a complex range of barriers that hinder the implementation of shared decision-making, including challenges related to the individuals mental capacity and level of engagement, managing disagreements, type and level of risk, quality of therapeutic relationships, fear of causing distress or disengagement, and environmental constraints such as time, resources and place of meeting. Enabling factors included a supportive multi-disciplinary team, training they received as part of education and practice, clinical experience providing them with skills, and a belief that equipping individuals with knowledge and understanding of their risk and safety could help them to manage it more effectively. ConclusionThe findings of this study may inform future intervention design to enhance collaboration in the assessment and management of risk and support current clinical practice in this area.

BackgroundRates of compulsory detention in psychiatric hospitals have risen over several decades in England and some other higher income countries. This study explores clinicians perspectives on how service users come to be compulsorily detained in psychiatric hospitals and their suggestions for reducing these detentions in the future. MethodsSemi-structured qualitative interviews were conducted with 23 clinicians working with individuals who have been compulsorily detained under the Mental Health Act in England. Interviews were carried out by telephone or videoconference. Data were analysed using template analysis. ResultsThree major themes were identified, with multiple sub-themes (a) service user factors that increase risk of compulsory detention, including high levels of risk, previous/underlying trauma, medication non-adherence, service user perceptions of their mental health state, disadvantage and discrimination, and lack of stability and involvement from family and social networks; (b) service-level reasons for being detained, including lack of communication and continuity of care, historical inability to obtain trust and confidence from parts of population, clinician biases and assumptions, lack of resources, lack of treatment and care variety, and systemic/institutional barriers to engagement; and (c) ways to improve services to reduce compulsory detainment, including increasing quality of care and patient/family level interventions, investing in services, offer choice regarding medication, offer alternatives to compulsory detention, and improve discharge planning. ConclusionsFindings suggested clinicians see that at least some compulsory hospital admissions as avoidable, particularly through better resourced and more accessible services and changes in staff attitudes to address unconscious biases and promote collaborative care. Our findings provide a range of potential means to reduce detentions, which warrant development and testing in research and practice.

It is estimated that one in four people will experience poor mental health throughout their lifetime. However, ethnic minority groups, refugees and asylum seekers experience more barriers accessing mental health services and have poorer mental health outcomes than those from non-ethnic minority groups. Evidence suggests that interventions that improve access and engagement with mental health services may help reduce disparities affecting ethnic minority groups. This review aims to assess the effectiveness of interventions that enhance equitable or overall access to mental health services by ethnic minority groups. The review included evidence available up until 19th December 2023. Psycho-educational interventions that focused on providing culturally appropriate information, showed mixed results for help seeking behaviour, improvements in depressions stigma. Multi-component interventions within healthcare settings had mixed results. Some studies showed positive outcomes; such as increased help seeking intentions and improved attendance rates, while others did not show significant differences in outcomes. Interventions that included integrating specialist mental health services within primary care resulted in variable outcomes. The findings of interventions incorporating language support into mental health services were also variable. The effectiveness of interventions to enhance the cultural competency of mental health services varied across studies.

BackgroundCorrect clinical diagnosis at the first episode of psychosis may be difficult due to many non-specific symptoms. We aimed to determine the factors associated with a correct diagnosis among patients with a first episode of psychosis in Uganda. MethodsA cross sectional study design was performed at the Butabika National Referral Mental Hospital in Uganda. We included treatment naive participants aged 18 to 60 years with a diagnosis of a psychotic disorder. Patients with organic disorders like HIV/AIDS, syphilis and substance use disorders were excluded. The MINI international neuropsychiatric inventory was administered to confirm the clinical diagnosis. Concordance was based on the percentage agreement and kappa statistic between the admission chart diagnosis and the MINI diagnosis. Results178 participants with a first episode of psychosis were included into the final analysis. The agreement between the MINI diagnosis and clinician diagnosis was 0.385, (P < 0.001) with a concordance of 49.5%. After controlling for nationality and the households source of income, duration of untreated psychosis, [p-value 0.028(95%CI: 0.07-0.89)], living with a primary family member, [p-value 0.038(95%CI:0.95-2.86)] and cadre of the clinician who made the initial diagnosis[Medical officer, [p-value 0.011(95%CI: 0.18-0.80)] were associated with a correct diagnosis. ConclusionWe found low agreement between clinician diagnoses and MINI diagnoses at the first episode of psychosis. Improved training of staff while considering the duration of untreated psychosis and the living arrangements of the patient are required to improve diagnostic accuracy in this population.

BackgroundFamily caregivers of patients with chronic illnesses face significant mental, physical, and financial burdens because of caregiving. This burden is worse in caregivers of patients with severe mental illness such as schizophrenia. The present study assessed the psychological burden and quality of life of caregivers of schizophrenic patients in selected mental health facilities in Accra, Ghana. MethodThis was an observational cross-sectional study conducted among 201 caregivers of patients with schizophrenia attending the psychiatric outpatient departments at Pantang and Accra Psychiatric Hospitals. Structured questionnaires: the Zarit Burden Interview and the Depression, Stress, and Anxiety Scale-21 items (DASS-21), the WHO-QOL BREF instrument and the 12-item proxy administered WHO Disability Assessment Schedule 2.0 (WHO-DAS 2.0) were used to collect data from the study respondents. FindingsThe study revealed that 37% of caregivers reported a high burden (ZBI score >16). The mean ZBI score was 14.3 (SD=8.7) on a scale of 0 to 48. The QOL scores for each domain were measured on a scale from 0 to 100: physical domain - 68.0 (SD=16.5), psychological domain - 64.5 (SD=17.2), social domain - 51.8 (SD=21.3), and environmental domain - 57.9 (SD=14.6), with higher scores corresponding to higher quality of life. Also, female caregivers, caregivers of unemployed patients, caregivers of patients who use substances, and caregivers with higher stress levels experienced higher levels of caregiver burden. In addition, the quality of life was higher for caregivers of employed patients and caregivers who had family support. Finally, lower perceived levels of patient functioning were found to be associated with higher levels of caregiver burden and a lower quality of life of the caregiver. ConclusionThe findings show that caregivers of patients with schizophrenia have a relatively high burden and average quality of life. Family support and job opportunities for patients with schizophrenia can help remedy these.

BackgroundPoor patient retention and family engagement compromise the effectiveness of coordinated specialty care (CSC) for first-episode psychosis (FEP). This mixed methods study aimed to identify program-level characteristics (CSC fidelity and engagement strategies) associated with patient retention and family engagement in Massachusetts CSC programs. MethodsPrimary outcomes were rates of patient retention and family engagement ([&ge;]1 evidence-based family intervention session), based on CSC program census (October 2022 - September 2023). Quantitative analyses explored program characteristics (EPINET Program-Level Core Assessment Battery) and fidelity ratings (Massachusetts Psychosis Fidelity Scale) as predictors using t-tests or univariate linear regressions. Thematic analysis of program interviews compared patient and family engagement strategies employed by high versus low performing programs. ResultsAcross nine programs, mean patient retention was 86% (range: 58-97%) and family engagement was 40% (range: 12-100%). Higher fidelity to evidence-based services (e.g., individual therapy, family intervention, and supported education/employment) was significantly associated with both outcomes (p<.05; R2 range: .51-.72). Mixed-methods analysis showed that high performing programs used case management-related supports to meet service users practical needs. Factors associated with higher patient retention included having comprehensive intake assessments, provider visits during hospitalization, and periodic treatment reviews. Programs that conducted benefits counseling and proactively recommended family services as standard care had higher family engagement. ConclusionsHigher fidelity CSC programs had better patient retention and family engagement. Case management-related supports addressed treatment barriers. Strategies designed to strengthen therapeutic alliance and goal alignment may promote patient engagement, while family engagement may benefit from proactive recommendation of family intervention.

There is an urgent need for services to address the social and economic adversities which contribute to the aetiology and outcomes of mental health problems. However, the implementation of interventions to do so is inconsistent, and entrenched cycles of poor mental health and social exclusion persist. We conducted a service evaluation survey of 28 staff working across community and inpatient teams, enhanced by a series of in-depth case studies, in the largest NHS mental health trust in the UK to explore how social and economic needs are currently assessed and addressed. We found that assessment for social and economic needs varied across different domains; for example, family relationships were more consistently assessed than domains such as education and income. A range of support is available and provided by a patchwork of teams, including Community Mental Health Teams, other NHS teams, Local Authority staff, and many third sector organisations. However, what support is available is severely restricted and respondents highlighted a lack of adequate support in every domain we considered - employment, education and training, social participation and connectedness, family relationships, community support, social security, debt, income, housing, and trauma and victimisation, as well as additional domains including healthy eating, sex and relationships, and activities of daily living. Nevertheless, our case studies illustrate examples of approaches to addressing social and economic needs to improve outcomes for people with mental health problems.

BackgroundPatient-reported outcomes (PRO) have been shown to improve screening and assessment across health care. However, overall implementation of PROs is low in mental health care. Research on PRO implementation in psychiatric urgent care settings is particularly limited. ObjectiveTo analyze barriers and facilitators to the implementation of electronic PROs (ePROs) in psychiatric urgent care clinics. MethodsThis study examined ePRO implementation at two Maryland clinics with an average 6,000 patients treated annually. These clinics offer "walk-in" services for patients seeking immediate assessment for mental health conditions and referral to appropriate follow-up care. We used the Learning Evaluation (LE) and RE-AIM frameworks to guide and evaluate the implementation of PROs into administrative and clinical workflows using an ePRO system. Stakeholder feedback informed rapid iteration cycles, driving the development and deployment of technical and procedural modifications. Quantitative data were organized using RE-AIM metrics and analyzed through descriptive statistics and regression analyses. Qualitative data, derived from stakeholder feedback, were analyzed using deductive coding, inductive coding, and sentiment analysis. Findings22,610 care episodes were analyzed for the study. Annual ePRO completion increased from 9% in 2021 to 44% in 2023, averaging 63% post-implementation. ePRO completion varied across clinics and was lower among males, Black patients, and those with neurocognitive or substance use disorders, but higher for anxiety, ADHD, and insomnia diagnoses. Adoption increased in 2023, with 17% of care episodes including ePRO data in provider notes, averaging 59% post-implementation. Six iterative modifications were implemented, assisting with ePRO completion and documentation to varying degrees. Qualitative analyses revealed administrative, clinical, and technological factors associated with ePRO implementation and completion rates, as well as an overall positive sentiment towards ePROs. ConclusionThe findings demonstrate the feasibility and sustainability of ePRO implementation in psychiatric urgent care settings. Clinical ImplicationsIterative strategies, informed by stakeholder feedback, assist with ePRO implementation in fast-paced clinical environments and can inform future quality improvement efforts for modernization of administrative workflows and clinical practice. What is already known on this topicO_LIWhile research supports patient-reported outcomes (PROs) as effective in mental health treatment when used, multiple barriers have limited their implementation in clinical practice. Currently there is limited knowledge of implementation in psychiatric urgent care settings. C_LI What this study addsO_LIUsing established implementation and evaluation frameworks, we were able to identify and overcome individual and organizational barriers of PRO implementation in psychiatric urgent care. C_LIO_LIWe found that continuous communication and feedback can help clinicians and staff with implementation. Iterative modification development based on feedback can improve patient reach and adoption of PROs in clinical practice. C_LI How this study might affect research, practice or policyO_LIOur findings contribute to gaps in the literature about PRO implementation in psychiatric urgent care and expands on technological and administrative processes that can resolve known barriers to implementation. The methodology used in this study can be modified to numerous real-world healthcare settings for evidence-based quality improvement interventions. C_LI

BackgroundMany randomised control trials struggle to recruit and retain participants. Few previous studies explore participants experiences of recruitment and engagement in trials in secondary mental health care contexts, and few include the perspectives of control group participants. We addressed this knowledge gap in a sub-study of the Community Navigator trial, a multi-site UK trial of a novel, co-produced, social intervention for people with Treatment Resistant Depression (TRD) in secondary care community mental health teams. We used a mixed methods approach to explore barriers and facilitators to trial recruitment and retention, intervention engagement, and how these factors may persist and inter-relate. MethodsSemi structured interviews were conducted with 17 trial participants and with intervention providers: eight Community Navigators and one supervisor, across four UK sites. An online survey was sent to the first 100 trial participants, which could be completed anonymously. Collaborative framework analysis was used by the research team and lived experience advisory panel (LEAP) to analyse interview, focus group and survey data. ResultsFactors helping and hindering trial recruitment and engagement were described in three overarching themes: The Trial Context, Skilled Communication, and The Complexity of Depression and Anxiety. Facilitators included: maximising choice for participants at all stages, a kind and patient approach and striking the correct balance between too much and too little information about the trial. A novel finding was that researchers initiate a "virtuous cycle", where participants initial good experience generates optimism about future involvement in the trial and the experimental treatment. Barriers to recruitment and engagement included referring clinicians providing inaccurate initial information to service users, overwhelming volumes of information, concern about randomisation to the control group, and service users internal barriers regarding their mental health. ConclusionWe generated learning for future trials in mental health contexts. Consideration of how to minimise disappointment following allocation to a control group is important. A kind and patient approach from researchers is essential, and a good early experience of the research process can help trial retention and generate therapeutic optimism about the trial intervention. Trial registrationRegistered on 8 th July 2022: ISRCTN 13205972