Review: Alternatives to inpatient care for children and adolescents with mental health disorders

Outcomes for Adaptive Mentalization Based Integrative Treatment informed care for adolescents using a deployment-based approach

PURPOSE

Adolescent mentalisation-based integrative therapy (AMBIT) is a whole-systems approach designed to enhance the effectiveness and coordination of care for clients experiencing severe and pervasive difficulties in social and health care settings, who have not responded to traditional clinical approaches. AMBIT is a team-based manualised method that primarily aims to bolster mental state understanding and discourse focused on the client within and between teams. Over 300 teams worldwide have been trained in and adhere to AMBIT principles.

METHOD

In this paper, we review and summarise the outcomes reported by eight AMBIT-informed teams that have published their findings with young people. Each report is discussed, and limitations of the data provided are identified.

RESULTS

A synthesis of the findings across the studies suggests a generally positive impact of teams informed by AMBIT with moderate to large effect sizes on reducing symptoms and improving functionality.

CONCLUSIONS

This study suggests that AMBIT may be a promising approach for young people with multiple problems but further research is needed to identify the active mechanisms of change in complex helping systems.

Short Research Article: Opening a new CAMHS day hospital - does it affect inpatient admissions and does it help at all?

BACKGROUND

Day hospitals in child and adolescent mental health services are held to be helpful entities in the psychiatric care of young people. However, limited research has been done to look into how day hospitals and similar settings affect referrals, inpatient stays and in which cohort of patients do they show the most impact. This study's primary aims were to examine the impact of a new Child and Adolescent Mental Health Service (CAMHS) day hospital on referrals and admissions to the associated CAMHS in-patient unit. A secondary aim of this study was to examine the demographics and clinical outcomes of the young people attending the day hospital.

METHODS

Information was gathered using retrospective reviews of clinical files and databases.

RESULTS

There was a reduction in admissions and in the total bed days from the study area following the opening of the day hospital. There was an improvement in clinical outcomes for young people attending the day hospital.

CONCLUSION

Day hospital in child and adolescent mental health services can prove to be a useful modality to provide support to young people with a moderate to severe mental illness leading to reduced inpatient admissions and improving lengths of inpatient stay. It also improves clinical outcomes for cohorts of young people where inpatient stay is not warranted but higher levels of support is needed.

Youth Crisis: The Current State and Future Directions

The number of children and youth experiencing behavioral health crisis in the United States is substantially increasing. Currently, there are shortages to home-based and community-based services as well as psychiatric outpatient and inpatient pediatric care, leading to high emergency department utilization. This article introduces a proposed crisis continuum of care, highlights existing evidence, and provides opportunities for further research and advocacy.

Effectiveness of home treatment in children and adolescents with psychiatric disorders-systematic review and meta-analysis

BACKGROUND

Home treatment in child and adolescent psychiatry offers an alternative to conventional inpatient treatment by involving the patient's family, school, and peers more directly in therapy. Although several reviews have summarised existing home treatment programmes, evidence of their effectiveness remains limited and data synthesis is lacking.

METHODS

We conducted a meta-analysis on the effectiveness of home treatment compared with inpatient treatment in child and adolescent psychiatry, based on a systematic search of four databases (PubMed, CINAHL, PsychINFO, Embase). Primary outcomes were psychosocial functioning and psychopathology. Additional outcomes included treatment satisfaction, duration, costs, and readmission rates. Group differences were expressed as standardised mean differences (SMD) in change scores. We used three-level random-effects meta-analysis and meta-regression and conducted both superiority and non-inferiority testing.

RESULTS

We included 30 studies from 13 non-overlapping samples, providing data from 1795 individuals (mean age: 11.95 ± 2.33 years; 42.5% female). We found no significant differences between home and inpatient treatment for postline psychosocial functioning (SMD = 0.05 [- 0.18; 0.30], p = 0.68, I2 = 98.0%) and psychopathology (SMD = 0.10 [- 0.17; 0.37], p = 0.44, I2 = 98.3%). Similar results were observed from follow-up data and non-inferiority testing. Meta-regression showed better outcomes for patient groups with higher levels of psychopathology at baseline and favoured home treatment over inpatient treatment when only randomised controlled trials were considered.

CONCLUSIONS

This meta-analysis found no evidence that home treatment is less effective than conventional inpatient treatment, highlighting its potential as an effective alternative in child and adolescent psychiatry. The generalisability of these findings is reduced by limitations in the existing literature, and further research is needed to better understand which patients benefit most from home treatment.

TRIAL REGISTRATION

Registered at PROSPERO (CRD42020177558), July 5, 2020.

Service design for children and young people with common mental health problems: literature review, service mapping and collective case study

Background

The mental health of children/young people is a growing concern internationally. Numerous reports and reviews have consistently described United Kingdom children's mental health services as fragmented, variable, inaccessible and lacking an evidence base. Little is known about the effectiveness of, and implementation complexities associated with, service models for children/young people experiencing 'common' mental health problems like anxiety, depression, attention deficit hyperactivity disorder and self-harm.

Aim

To develop a model for high-quality service design for children/young people experiencing common mental health problems by identifying available services, barriers and enablers to access, and the effectiveness, cost effectiveness and acceptability of such services.

Design

Evidence syntheses with primary research, using a sequential, mixed-methods design. Inter-related scoping and integrative reviews were conducted alongside a map of relevant services across England and Wales, followed by a collective case study of English and Welsh services.

Setting

Global (systematic reviews); England and Wales (service map; case study).

Data sources

Literature reviews: relevant bibliographic databases and grey literature. Service map: online survey and offline desk research. Case study: 108 participants (41 children/young people, 26 parents, 41 staff) across nine case study sites.

Methods

A single literature search informed both reviews. The service map was obtained from an online survey and internet searches. Case study sites were sampled from the service map; because of coronavirus disease 2019, case study data were collected remotely. 'Young co-researchers' assisted with case study data collection. The integrative review and case study data were synthesised using the 'weaving' approach of 'integration through narrative'.

Results

A service model typology was derived from the scoping review. The integrative review found effectiveness evidence for collaborative care, outreach approaches, brief intervention services and the 'availability, responsiveness and continuity' framework. There was cost-effectiveness evidence only for collaborative care. No service model appeared to be more acceptable than others. The service map identified 154 English and Welsh services. Three themes emerged from the case study data: 'pathways to support'; 'service engagement'; and 'learning and understanding'. The integrative review and case study data were synthesised into a coproduced model of high-quality service provision for children/young people experiencing common mental health problems.

Limitations

Defining 'service model' was a challenge. Some service initiatives were too new to have filtered through into the literature or service map. Coronavirus disease 2019 brought about a surge in remote/digital services which were under-represented in the literature. A dearth of relevant studies meant few cost-effectiveness conclusions could be drawn.

Conclusions

There was no strong evidence to suggest any existing service model was better than another. Instead, we developed a coproduced, evidence-based model that incorporates the fundamental components necessary for high-quality children's mental health services and which has utility for policy, practice and research.

Future work

Future work should focus on: the potential of our model to assist in designing, delivering and auditing children's mental health services; reasons for non-engagement in services; the cost effectiveness of different approaches in children's mental health; the advantages/disadvantages of digital/remote platforms in delivering services; understanding how and what the statutory sector might learn from the non-statutory sector regarding choice, personalisation and flexibility.

Study registration

This study is registered as PROSPERO CRD42018106219.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information.

Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase

BACKGROUND

Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies.

METHODS

This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers.

DISCUSSION

This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain.

TRIAL REGISTRATION

ISRCTN ISRCTN42999542, Registration on April 29, 2020.

A snapshot in time: a 1-month review of all referrals to paediatric liaison psychiatry services in Dublin following emergency department presentation

INTRODUCTION

An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres.

METHODS

Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored.

RESULTS

Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of 39 females (66%) with a mean age of 13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting (n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission rates and length of stay.

DISCUSSION

Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.

Intensive community care services for children and young people in psychiatric crisis: an expert opinion

BACKGROUND

Children and young people's (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails.

METHODS

A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up.

RESULTS

ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children's Global Assessment Scale were agreed.

CONCLUSIONS

This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Treatment outcome of an intensive psychiatric home treatment for children and adolescents: a non-randomized controlled pilot evaluation

Home treatment (HT) may offer an effective and cost-efficient alternative to inpatient treatment for children and adolescents with acute mental disorders. This study introduces and evaluates a pilot HT project from Bern, Switzerland, with HT completely replacing an inpatient treatment. A total of n = 133 children and adolescents with acute mental disorders and inpatient treatment needs were treated either in the new HT program (n = 37) or in an active control group with inpatient treatment as usual (I-TAU, n = 96). Psychopathological burden was assessed by the Health of the Nation Outcome Scale for Children and Adolescents clinician-rated (HoNOSCA) and self-rated (HoNOSCA-SR) at the time of admission and at discharge. Treatment effects were assessed and compared using Augmented Inverse Probability Weights to adjust for baseline differences and to control for treatment duration. Participants ranged in age from 6 to 17 years (M = 13.71 years, SD = 2.93), 54% were female. HT resulted in significant improvements in the HoNOSCA (d = 0.79, p < .001) and HoNOSCA-SR (d = 0.63, p = .006). No significant differences on treatment effects were observed between HT and the reference group I-TAU in the HoNOSCA (d = 0.01, p = .96) or the HoNOSCA-SR (d = 0.11, p = .63). Overall, results indicate HT to be an effective alternative for children and adolescents with acute mental health disorders instead of hospitalization. Further evaluation with random group allocation and long-term follow-up should attempt to replicate and extend the current findings.

Intensive community and home-based treatments for eating disorders: a scoping review study protocol

INTRODUCTION

Institutionally based intensive treatment modalities (inpatient, day patient and residential treatments) for eating disorders (EDs) are associated with high treatment costs and significant challenges for patients and carers, including access difficulties and disruption to daily routines. Intensive community and home-based treatments have been suggested as alternatives to institutionally based intensive treatments for other severe mental illnesses, with promising clinical, social and health economic outcomes. The possible advantages of these treatments have been proposed for EDs, but this emerging area of research has not yet been systematically investigated. This scoping review aims to map the available literature on intensive community and home treatments for EDs, focusing on their conceptualisation, implementation and clinical outcomes.

METHODS

This proposed scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. This review will include any peer-reviewed study concerning intensive community and home-based treatments for any EDs, with no restrictions on geographical context or study design. Grey literature will also be considered. The literature search will be conducted in four databases: PubMed, PsycInfo, MEDLINE and Web of Science. Two researchers will independently screen the titles, abstracts and text of the returned articles for eligibility. Data charting and analysis will consist of a narrative description of the included studies, quantitative and qualitative findings relative to the aims of this scoping review. Gaps in the literature will be highlighted to inform future research, clinical practice, and policy.

ETHICS AND DISSEMINATION

Ethical approval is not required as all data are available from public sources. The results of this scoping review will be disseminated through peer-reviewed publication, conference presentation, and social media.

Adolescent inpatient mental health services in the UK

Inpatient mental health services are an indispensable part of the mental healthcare for adolescents. They provide comprehensive assessment and treatment for young people severely affected by mental health difficulties whose presentation is associated with high level of risk or where diagnostic clarity and effective intervention cannot be achieved with less intensive community input. In the UK, a range of different mental health units have been developed with the aim to meet the needs of young people requiring admission with the appropriate expertise and in the least restrictive way possible. Although an inpatient admission is necessary and helpful for a number of adolescents, it may also be linked to some adverse effects that need to be carefully assessed and managed when such an option is considered or pursued. Collaborative working between inpatient units, community teams and young people and their families is paramount in ensuring that inpatient interventions form part of a wider treatment plan, are as efficient and effective as possible and are used in a way that fosters engagement, independence and optimal outcomes.

Integrating home treatment into the Austrian child and adolescent mental health care system: an implementation science perspective

BACKGROUND

In Austria, similar to other countries, health care planners have considered implementing home treatment (HT) programs for children and adolescents with mental health problems. However, introducing any new service innovation into the complex environment of the child and adolescent mental health care system requires context and implementation issues to be taken into account in advance.

METHODS

We identified implementation themes from international HT models and developed a questionnaire with open-ended implementation-related questions for Austrian professionals. We analysed the qualitative results alongside the domains in the Context and Implementation of Complex Interventions (CICI) framework to detect key implementation challenges for HT in Austria.

RESULTS

We found six implementation themes in international HT models, which formed the basis for development of the questionnaire. Within the qualitative data from ten Austrian professionals who responded to the questionnaire, we identified implementation challenges in all eight context and all four implementation domains of the CICI framework.

CONCLUSIONS

Key implementation challenges detected highlight the need to address the fit of HT within existing sociocultural norms and limited available human resources. Regional context-specific solutions need to be found on how to embed this new element best into the existing provider and financing structures. This calls for monitoring and evaluation alongside implementation to support decision-making.

The Impact of Community Mental Health Programs for Australian Youth: A Systematic Review

Australia has undergone significant youth mental health reform over the past 10 years, leading to numerous studies examining the effects of community-based mental health care programs for Australian youth. However, no synthesis of this literature currently exists. Therefore, this systematic review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A systematic search of the peer-reviewed literature was conducted. Studies were included if they evaluated the extent to which such programs improved mental health symptomology (e.g., depression, anxiety, substance use) and/or psychosocial outcomes (e.g., social functioning, school engagement, employment) for Australian youth aged 10–25 years. Thirty-seven studies were included. Four types of community-based youth mental health care programs were identified: therapy (n = 16), case management (n = 9), integrated ‘one-stop-shop’ (n = 6) and lifestyle (n = 6) programs. The majority of therapeutic programs were effective in reducing mental health symptomology. Case management and integrated approaches consistently yielded significant improvements in both symptomology and psychosocial outcomes. Lifestyle programs were effective in alleviating depressive symptoms, but inconclusive for other outcomes. This review provides support for youth-friendly, systemic, multidisciplinary and integrated assertive outreach models of community mental health care to improve outcomes for young Australians experiencing mental health concerns. Several recommendations for future research are provided to strengthen the local evidence-base supporting community mental health programs to ultimately enhance young people’s life trajectory.

Alternatives to mental health admissions for children and adolescents experiencing mental health crises: A systematic review of the literature

Background: Many children and young people (CYP) presenting with mental health crises are admitted to hospital due to concerns around illness severity and risk. Whilst inpatient admissions have an important role for such children, there are a number of burdens associated with them, and safe avoidance of admissions is favourable. We systematically reviewed the literature for studies of interventions reported as alternatives to a hospital admission in CYP presenting with mental health crises, in any inpatient setting. Methods: Three databases (PsychInfo, PubMed and Web of Science) were searched for peer-reviewed papers in October 2020, with an updated search in May 2021. Results: We identified 19 papers of interventions delivered in the emergency department, the home, outside of home but outside of clinics and in hospital clinics. The quality of most included studies was low, with less than half being randomised controlled trials and only half of these at low risk of bias. The best quality studies and greatest evidence for efficacy came from in-home interventions, in particular multisystemic therapy, which improved psychological outcomes, and though a large number of CYP still ended up being admitted, there appeared to be decreased length of stay. Conclusions: Overall, we could not recommend a particular intervention as an alternative to inpatient admission; however, our review describes benefits across a range of types of interventions that might be considered in multi-modal treatments. We also provide recommendations for future research, in particular the evaluation of new interventions as they emerge.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Multi-center nationwide study on pediatric psychiatric inpatients 2000-2018: length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnostic profiles

Inpatient treatment is an important part of child and adolescent psychiatric (CAP) care. This nationwide study explores the changes in length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnoses of CAP inpatients in Finland in 2000, 2011 and 2018. We obtained comprehensive questionnaire data on each study year from 93 to 95% of all CAP wards in Finland. We split the 1276 inpatients into two age groups in each study year: under 13 and 13-18. The median length of stay in inpatient treatment decreased from 82.0 days in 2000 to 20.5 days in 2018 (p < 0.001) and recurrent hospitalization increased from 38 to 46%. General functioning, which was evaluated by the Children's Global Assessment Scale, deteriorated by an average of six points between 2000 and 2018. Violent threats decreased from 21.5 to 16.6% and violent acts decreased from 26.9 to 20.3%. Suicidal threats decreased from 42.6 to 23.3% in those aged under 13 and remained stable among those aged 13-18. In the 13-18 group, there was an increase in the diagnoses of ADHD, from 5.0 to 16.9% and depression, from 25.1 to 41.7%. However, psychosis decreased from 23.2 to 12.6% in the older age group. In the whole cohort, anxiety disorders increased from 7.6 to 15.6%. The overall picture does not show that CAP inpatients have become more disturbed. While the general functioning of CAP inpatients deteriorated somewhat over the 2000-2018 study period, symptoms of suicidality and violence remained stable or decreased. There was also a continuous increase in short-term treatment.

Long-term outcome of intensive home treatment for children and adolescents with mental health problems - 4 years after a randomized controlled clinical trial

BACKGROUND

Admission rates to child and adolescent mental health inpatient units in Germany are substantial (58.831 admissions in 2019). Historically, different treatment pathways have not been available. The evidence suggests that home treatment could be an alternative. The objective of this study was to assess the long-term stability of treatment gains among children and adolescents treated for serious mental health problems with home treatment (HT) as compared with inpatient treatment-as-usual (TAU).

METHODS

Hundred patients were enrolled and randomized into an intervention (HT n = 54) and control group (TAU n = 46). Follow-up data were available after 8.4 months (n = 78) (T3) and after 4.3 years (n = 51) (T4). The primary outcome measured was overall level of functioning, for which the Children's Global Assessment Scale (CGAS) was used. Secondary outcomes included severity of patient impairment and parental competency in dealing with their child's symptoms, measured using the Health of the Nation Outcome Scales (HoNOSCA). A qualitative interview with parents was performed at T3 and T4.

RESULTS

Treatment effects remained stable for both groups at T3 and T4 (p < .001). After 4.3 years 70% of the parents in the intervention group stated satisfaction with the treatment received, while only 36.8% of the parents within the control group rated themselves as satisfied. 43.7% of parents in the home treatment group reported that the most helpful aspect of this pathway was the prompt and intensive professional help and advice they received as primary caregivers at home.

CONCLUSIONS

Home treatment may be considered a viable alternative to inpatient care.

[Effectiveness and Safety of Home Treatment in Child and Adolescent Mental Health Care: A Systematic Literature Review]

OBJECTIVE

In child and adolescent psychiatry, home treatment is becoming increasingly important due to limited inpatient care capacities and changing treatment philosophies. This paper examines its effectiveness and safety.

METHODS

We did a systematic literature search and summarized the home treatment model characteristics as well as the evidence on its benefits and harms narratively.

RESULTS

In the six identified studies, improvements in symptoms were found in both, home and institutionalized treatment. In the long-term, home treatment seems to be slightly superior and involves fewer hospital days. However, a best-practice model cannot be derived from the data available.

CONCLUSION

Home treatment can be considered as an alternative to inpatient treatment, but requires coordination with other mental health care elements and further evaluation.

Environmental changes to reduce self-harm on an adolescent inpatient psychiatric ward: an interrupted time series analysis

Existing interventions to reduce self-harm in adolescents admitted to psychiatric wards are usually focused on individual psychological treatments. However, the immediate ward environment in which treatment takes place is an important factor in the success of the treatment and can also influence the likelihood of self-harming behaviours. The aim of the current study was to evaluate changes made to a psychiatric ward environment on incidence of self-harm in adolescents. A quasi-experimental interrupted time series study was conducted on one child and adolescent psychiatric ward. An intervention was developed alongside staff and patients to address the high incidence of self-harm on weekday evenings on the ward. The intervention components involved adding a regular twilight shift (3-11 pm) for nursing staff and introducing a structured evening activity programme on the ward. A segmented regression analysis of an interrupted time series found that the rate of self-harm per 100 bed days was already declining at baseline and continued to decline post-intervention, but the rate of decline was not significant (p = 0.415). However, the proportion of patients self-harming was increasing at baseline and significantly reduced post-intervention (p = 0.001), and this reduction was significantly larger in the evenings (p = 0.004) compared to other times of day (p = 0.09). A tailored intervention targeting the psychiatric ward environment helped to reduce the proportion of adolescents self-harming on the ward. An interrupted time series analysis should be considered for future interventions making changes to health systems over time.

Debate: Feeling understood in a fake world - the place of inpatient mental health units in the care of children and adolescents

Inpatient units are a significant element of mental healthcare for children and adolescents with the most severe and challenging clinical presentations. Inpatient input has been associated with substantive and sustained health gains across a range of diagnoses and cannot be fully replaced by intensive community treatment options. The potential benefits and risks associated with an admission should be carefully weighed in all referred individuals and may differ depending on several parameters including the type of unit and aims of admission. Although every effort should be made for admissions to be as efficient and short as possible, access to inpatient care and its extent should continue to be determined by clinical need.

Debate: The future of inpatient units - do we need them?

There will always be a need for some inpatient beds. However, in this paper we highlight some of the potential risks and harms from admission and suggest that for many children and young people intensive community interventions would result in better outcomes, improved patient experience and be more cost-effective.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth

As hospital beds are scarce, and emergency admissions to a psychiatric ward are major life-events for children and adolescents, it is essential to have insight into the decision-making process that leads to them. To identify potentially modifiable factors, we, therefore, studied the contextual and clinical characteristics associated with the voluntary and compulsory emergency admission of minors. We used registry data (2008-2017) on 1194 outpatient emergencies involving children aged 6-18 who had been referred to the mobile psychiatric emergency service in two city areas in The Netherlands. Demographic and contextual factors were collected, as well as clinical characteristics including diagnoses, psychiatric history, Global Assessment of Functioning (GAF), and the Severity of Psychiatric Illness (SPI) scale. Logistic regression analyses were used to identify factors that predict voluntary or compulsory admission. Of 1194 consultations, 227 (19.0%) resulted in an admission, with 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) compulsorily. Independently of legal status, the following characteristics were associated with admission: severity of psychiatric symptoms, consultation outside the patient's home, and high levels of family disruption. Relative to voluntary admission, compulsory admission was associated with more severe psychiatric problems, higher suicide risk, and prior emergency compulsory admission. Two potentially modifiable factors were associated with psychiatric emergency admission: the place where patients were seen for consultation, and the presence of family problems. Psychiatric emergency admissions may be reduced if, whenever possible, minors are seen in their homes and if a system-oriented approach is used.

Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm, functional impairment, and educational and clinical outcomes

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12-18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05-0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2-208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.

Kinder- und jugendpsychiatrische stationsäquivalente Behandlung (StäB): Therapieoption – für alle oder für wenige?

Zusammenfassung. Fragestellung: Aufsuchende stationsäquivalente Behandlung (StäB) ist seit dem 01.01.2017 in Deutschland möglich und seit dem 01.01.2018 abrechenbar. Dennoch wird StäB unter Infragestellung der Machbarkeit der Rahmenbedingungen derzeit nur an wenigen Standorten der Kinder- und Jugendpsychiatrie und Psychotherapie in Deutschland regelhaft angeboten. Ziel war es, anhand der ersten 58 stationsäquivalent behandelten Kinder und Jugendlichen am ZfP Südwürttemberg (2018–2019) die Machbarkeit und Kosten von StäB zu evaluieren. Methodik: Es wurden alle seit dem 01.01.2018 konsekutiv stationsäquivalent behandelten Fälle eingeschlossen und anhand von rein deskriptiven Analysen in SPSS.25 evaluiert. Ergebnisse: Die durchschnittliche Behandlungsdauer betrug 37.95 Tage (SD 15.35), 86.2 % aller Familien beendeten die Behandlung regelgerecht, es kam nur bei drei Patientinnen und Patienten zu einem einvernehmlichen Behandlungsabbruch, fünf mussten in eine stationäre Behandlung verlegt werden. Es wurden primär internalisierende Störungen indiziert (70.7 %), während externalisierende Störungen nur ein Viertel der Behandlungsfälle ausmachten (27.8 %). Kosten einer StäB beliefen sich im Durchschnitt auf 8779,25 €. Schlussfolgerungen: StäB stellt eine neue Behandlungsform im familiären Umfeld dar, welche täglich stattfindet. Multiprofessionalität der Behandlung ist Voraussetzung. Eine Umsetzung in den gegebenen Rahmenbedingungen ist möglich. Eine Akzeptanz von den Familien ist gegeben, die durchschnittliche Behandlungsdauer liegt leicht über dem stationären Bundesdurchschnitt.

Editorial: Identifying Youths With Mood Disorders at High Short-Term Risk of Hospital Readmission

Children and adolescents with mood disorder diagnoses are at greater risk of psychiatric hospital admission than youths with disruptive disorder or even psychotic disorder diagnoses.^1,2 These youths account for more than two thirds of all child and adolescent mental health admissions to general hospitals, and they have a substantial risk of early hospital readmission after leaving the hospital.³ Yet despite these risks, surprisingly little attention has been devoted to identifying which child and adolescent inpatients with mood disorders are at particularly high risk of early hospital readmission. Progress in understanding these risks would help child and adolescent psychiatrists focus the most intensive follow-up efforts and interventions on their patients who are most vulnerable to early relapse.

[From home treatment to psychiatric ward-equivalent treatment (StäB) - A systematic review of outpatient treatment in Germany]

From home treatment to psychiatric ward-equivalent treatment (StäB) - A systematic review of outpatient treatment in Germany Abstract. Objective: In the past, home treatment was not available in Germany for children and adolescents with mental health problems. However, enactment of the PsychVVG law on 1 January 2017 has changed this, so that intensive home treatment (stationsäquivalente Behandlung, StäB) can now be offered as an alternative to inpatient treatment. This literature review a) analyzes existing German home treatment studies for effectiveness, b) determines from international reviews criteria for effective home treatment, and c) aligns these with the standardized StäB criteria. Method: We performed a systematic literature search in PubMed, Scopus, PsycINFO, and Cochrane Library referencing "hometreatment AND children" as well as "hometreatment AND adolesc*. Results: Flexibility, mobility, multiprofessionality, a wide spectrum of possible interventions, the option of inpatient admission, 24/7 availability as well as daily treatment sessions have been found to be factors for effective home treatment. In German studies, home treatment was shown to enhance psychosocial functioning, parental competences, long-term effectiveness, and acceptance by the families. The highest effect for home treatment was demonstrated in children and adolescents with externalizing disorders. Conclusion: Intensive home treatment (StäB) meets the criteria identified in the literature and is a good addition to existing treatment options for children and adolescents with mental health problems in Germany.

Experiences and satisfaction of children, young people and their parents with alternative mental health models to inpatient settings: a systematic review

Community-based mental health services for children and young people (CYP) can offer alternatives to inpatient settings and treat CYP in less restrictive environments. However, there has been limited implementation of such alternative models, and their efficacy is still inconclusive. Notably, little is known of the experiences of CYP and their parents with these alternative models and their level of satisfaction with the care provided. Therefore, the main aim of this review was to understand those experiences of the accessibility of alternative models to inpatient care, as well as overall CYP/parental satisfaction. A searching strategy of peer-reviewed articles was conducted from January 1990 to December 2018, with updated searches conducted in June 2019. The initial search resulted in 495 articles, of which 19 were included in this review. A narrative synthesis grouped the studies according to emerging themes: alternative models, tele-psychiatry and interventions applied to crisis, and experiences and satisfaction with crisis provision. The identified articles highlighted increased satisfaction in CYP with alternative models in comparison with care as usual. However, the parental experiential data identified high levels of parental burden and a range of complex emotional reactions associated with engagement with crisis services. Furthermore, we identified a number of interventions, telepsychiatric and mobile solutions that may be effective when applied to urgent and emergency care for CYP experiencing a mental health crisis. Lastly, both parental and CYP experiences highlighted a number of perceived barriers associated with help-seeking from crisis services.

Intensive home treatment for adolescents in psychiatric crisis

BACKGROUND

Adolescents with acute psychiatric disorders are typically treated with long-term clinical admission. However, long term admission may be associated with a variety of negative outcomes. This pilot study presents a new model of care, that is, the combined application of intensive home treatment and the possibility of short term stay at a psychiatric high & intensive care.

METHODS

In total 112 referred adolescents with mixed diagnoses participated in this longitudinal observational design. Clinical outcome was measured by the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) which measures the severity of multiple mental health problems. The HoNOSCA was clinician-rated at intake, after two months and after four months at discharge. Change in HoNOSCA total score was analysed with paired t-tests. Outcome moderators were gender, age, primary diagnosis, clinical admission, home treatment-time, medication and additional therapies. Follow up data were completed for 62 patients after two months and for 53 after four months.

RESULTS

Participants aged between 11 and 18 years (M = 14.8 years, SD = 0.3; 52% female). Mean HoNOSCA total score at intake was 18.8 (SD = 5.2), after two months 13.0 (SD = 5.0); after four months resulting in a score of 9.3 (SD = 5.2). None of the moderators tested showed a significant effect on HoNOSCA scores. However, a control group could not be used because of the severe psychopathology and high risk for suicidality and the lack of an effective treatment intervention for a comparable study group.

CONCLUSION

With a symptom decrease of over 50% within four months as measured by the HoNOSCA, including less risk for hospitalization, this new model appears promising and of clinical relevance. Nevertheless, further research regarding stability of treatment outcome is warranted and evaluation of long-term effects of this model in follow-up studies is needed.

Specialized Therapeutic Assessment-Based Recovery-Focused Treatment for Young People With Self-Harm: Pilot Study

Background: Suicide is the second leading cause of death in young people worldwide. Self-harm is the strongest predictor of death by suicide. There is increasing evidence that psychological therapies are efficacious in treating self-harm in adolescents. However, studies so far have predominantly focused on highly selective groups of adolescents and have investigated interventions that require intensive training and considerable expense. Methods: We conducted a pilot study of a novel psychological therapy package, Specialized Therapeutic Assessment-Based Recovery-Focused Treatment (START) that consists of Therapeutic Assessment followed by treatment in one of three modules, depending on adolescents' needs and preferences: Solution Focused Brief Therapy, Cognitive Behavior Therapy (CBT), or Mentalization Based Treatment. Adolescents (12-17) with at least one self-harm episode in the previous 6 months referred for community treatment, who had no intellectual disability, psychosis or autism were eligible for START. The primary outcome measure was the number of self-harm (regardless of suicidal intent) episodes 6 months before and 6 months after commencing START. Secondary outcomes included measures of psychopathology, functional impairment and family satisfaction. Results: Twenty-one consecutively referred adolescents were recruited and 15 received a therapeutic module of START: three received Solution Focused Brief Therapy, nine CBT, and three Mentalization Based Treatment. There was a statistically significant reduction in the number of self-harm episodes from a mean of 7.93 (SD = 12.26) to 1.00 (SD = 1.47), p < 0.02 following START. There was also a significant reduction in self-harm episodes, Revised Children's Anxiety and Depression Scale scores and a statistically significant improvement in Children Global Assessment Scale scores for the CBT group alone. There were no significant differences in any other outcomes. Most families were somewhat or very much satisfied with the intervention. Conclusion: The results show that START was associated with a reduction in self-harm and depression and anxiety symptoms, which could indicate that START should be rigorously studied in a randomized control trial (RCT). However, the model had difficulties in its implementation, with CBT being only module that was offered to enough young people to allow before and after analysis. CBT appears to be the most promising module in treating adolescents with self-harm referred to community mental health services.

Editorial: The job of an editor-one year on

Incredible as it still sounds to me, it has now been a year since I took over as the editor-in-chief of Child and Adolescent Mental Health. It is time to both look back and look forward. Over the past year, my approach remained unchanged: CAMH should grow to become a leading source of the most clinically relevant knowledge worldwide in our field. I would like you, our readers, to think of CAMH whenever you need clinical advice, a research update, or an innovative service development idea.

Suicidality among child and adolescent psychiatric inpatients: time trend study comparing 2000 and 2011

Child and adolescent inpatient treatment has faced major changes since the year 2000, including shorter inpatient stays and a greater use of psychotropic drugs. This study explored changes and correlates of suicidal threats and suicide acts among inpatients, by comparing Finnish cross-sectional surveys from 2000 to 2011. A questionnaire that explored the background, diagnosis and treatment characteristics of inpatients was sent to all child and psychiatric wards in Finland. The data collection was carried out on specified days in 2000 and 2011. We received comprehensive data on 504 patients from 64/69 (93%) wards in 2000 and on 412 patients from 75/79 (95%) wards in 2011. The Spectrum of Suicidal Behaviour Scale was used to explore suicidality. The prevalence of suicidality did not change in this nationwide study: suicidal threat rates were 38% in 2000 and 37% in 2011, and suicide attempts in both years were 11%. The prevalence of suicidal acts was higher among girls and teenagers, while low general functioning, defined as Children's Global Assessment Scale scores of under 30, was associated with both suicidal threats and acts. Violent acts were associated with both suicidal threats and acts in 2000, but not in 2011. Despite changes in treatment practices and shorter inpatient stays, the prevalence of suicidality in child and adolescent inpatient treatment remained unchanged in Finland in 2000 and 2011.

Review of services to inform clinical frameworks for adolescents and young adults with severe, persistent and complex mental illness

OBJECTIVE

Severe, persistent and complex mental illness (SPCMI) affects a small proportion of young people but is associated with severe disability and a large burden on families and health services. This article identifies and describes service models for adolescents and young adults with SPCMI.

METHODS

A systematic search was conducted for services for young people aged 12-25 years with SPCMI. The review sought service models providing extended care and/or multidisciplinary services to meet the complex and long-term needs of this population.

RESULTS

A total of 43 sources were identified. Evidence of effectiveness was found for both community- and bed-based services. Specific components suggested as important in service delivery included care provided by multidisciplinary teams, consumer and family involvement in care planning, intensive case management and service integration through the continuum of care.

CONCLUSION

Clinical frameworks for this population must incorporate effective community care integrated with inpatient treatment of short duration. Frameworks require consumer and family-centred care with flexibility to support progression through developmental stages and tasks while addressing issues related to risk management, fluctuation in illness severity and stages of recovery. A continuum of care is necessary to meet the needs that arise from SPCMI in adolescents and young adults.

Treatment Engagement in Specific Psychological Treatment vs. Treatment as Usual for Adolescents With Self-Harm: Systematic Review and Meta-Analysis

Background: Self-harm is a major public health problem. It is one of the best predictors of suicide in adolescents. Despite recent advances in the understanding of self-harm, poor treatment engagement remains a significant clinical obstacle. Objectives: The purpose of this meta-analysis is to update and extend previous research investigating treatment engagement with specific psychological treatments (SPT) vs. treatment as usual (TAU) in adolescents who self-harm. Methods: Data sources were identified by searching the Medline, PsychINFO, EMBASE, and PubMed databases as of October 2017. Randomized Controlled Trials (RCTs) comparing SPT and TAU in adolescents (through age 18 years) with self-harm were included. Results: The results show that 12 RCTs investigating 1,255 young people were included in the meta-analysis. The proportion of adolescents not completing four or more sessions in SPT was significantly lower (28.4%, 179/630) than TAU (45.9%, 287/625), RR = 0.64 (95% CI:0.51 -0.79), p < 0.0001. There were significantly more adolescents engaged with SPT than TAU. Conclusions: Specific psychological treatments should be offered to adolescents with self-harm to maximize treatment engagement. Engaging adolescents with psychological treatment is necessary although not sufficient to achieve treatment goals.

Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial

BACKGROUND

Intensive community treatment to reduce dependency on adolescent psychiatric inpatient care is recommended in guidelines but has not been assessed in a randomised controlled trial in the UK. We designed a supported discharge service (SDS) provided by an intensive community treatment team and compared outcomes with usual care.

METHODS

Eligible patients for this randomised controlled trial were younger than 18 years and had been admitted for psychiatric inpatient care in the South London and Maudsley NHS Foundation Trust. Patients were assigned 1:1 to either the SDS or to usual care by use of a computer-generated pseudorandom code with random permuted blocks of varying sizes. The primary outcome was number of inpatient bed-days, change in Strengths and Difficulties Questionnaire (SDQ) scores, and change in Children's Global Assessment Scale (CGAS) scores at 6 months, assessed by intention to treat. Cost-effectiveness was explored with acceptability curves based on CGAS scores and quality-adjusted life-years (QALYs) calculated from the three-level EuroQol measure of health-related quality of life (EQ-5D-3L), taking a health and social care perspective. This study is registered with the ISRCTN Registry, number ISRCTN82129964.

FINDINGS

Hospital use at 6 months was significantly lower in the SDS group than in the usual care group (unadjusted median 34 IQR 17-63 vs 50 days, 19-125, p=0·04). The ratio of mean total inpatient days for usual care to SDS was 1·67 (95% CI 1·02-2·81, p=0·04), which decreased to 1·65 (0·99-2·77, p=0·057) when adjusted for differences in hospital use before randomisation. Scores for SDQ and CGAS did not differ between groups. The cost-effectiveness acceptability curve based on QALYs showed that the probability of SDS being cost-effective compared with usual care was around 60% with a willingness-to-pay threshold of £20 000-30 000 per QALY, and that based on CGAS showed at least 58% probability of SDS being cost-effective compared with usual care irrespective of willingness to pay. We recorded no adverse events attributable to SDS or usual care.

INTERPRETATION

SDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies.

FUNDING

South London and Maudsley NHS Trust.

Editorial: The future of crisis mental health services for children and young people

The future of mental health services for children and young people are at a turning point. There is increasing recognition that there is huge unmet need. In the UK only approximately 25% of children and young people with a mental health disorder receive treatment, but demand to access care is increasing. At the same time evidence is building on what treatments are effective. This has not been matched by equivalent research evidence on what service configurations are most effective. In their systematic review of 'the impact of pediatric mental health care provided in outpatient, primary care, community and school settings on emergency department use', Kirkland et al (2018) found only limited evidence to suggest that the provision of services in the community impact on the use of emergency departments. The absence of robust RCT evidence should not prevent us from improving the outcomes and experience of children and young people facing a mental health crisis. Much is known about the value of early intervention and effective community interventions. Action should be taken now to prioritise the use of scarce resources where they are needed most to reduce unnecessary and sometimes unhelpful attendances at emergency departments and avoid potentially harmful mental health admissions.

Efficacy of multisystemic therapy in youths aged 10-17 with severe antisocial behaviour and emotional disorders: systematic review

BACKGROUND

Antisocial behaviour and conduct disorders are the most common behavioural and mental health problems in children and young people globally. An efficacious intervention is needed to manage these antisocial behaviours that have costly consequences. Multisystemic Therapy (MST), an intensive home-based intervention for youths with psychosocial and behavioural problems, is recommended under National Institute for Health and Clinical Excellence guidelines for conduct disorder. However, reviews on the efficacy of MST are mixed.

AIM

To review randomised controlled trials (RCTs) reporting efficacy of MST among youths presenting with antisocial behaviour and emotional disorder respectively.

METHOD

A systematic map term to subject heading search was conducted in PsycINFO, Embase, and Ovid Medline databases for articles up to November 2015. RCTs comparing MST vs.treatment as usual (TAU) in youths presenting with antisocial behaviour and emotional disorder were included.

RESULTS

12 RCTs (n = 1425) reported efficacy of MST vs. TAU in youths presenting with antisocial behaviour and emotional disorder. Clinically significant treatment effects of MST showed a reduction of antisocial behaviour which includes delinquency. MST, vs. psychiatric hospitalisation, was associated with a reduction of suicidal attempts in youths presenting with psychiatric emergencies. 4 studies showed that MST was less costly than TAU in the short term, with further analysis required for long-term cost-effectiveness.

CONCLUSION

MST is an efficacious intervention for severe antisocial behaviours in reduction of delinquency and should be included in clinical practices. MST was shown to have a positive effect on emotional disorder but further research is needed to evaluate the efficacy of MST with emotional disorder. Further analysis is required to assess the services utilized for long-term cost effectiveness.

Exploring professionals' understanding, interpretation and implementation of the 'appropriate medical treatment test' in the 2007 amendment of the Mental Health Act 1983

BACKGROUND

The appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available.

AIMS

As part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals' understanding of the ATT, and its impact on clinical practice.

METHOD

Forty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process.

RESULTS

We found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient's age rather than diagnosis. The ATT has had little impact on clinical practice.

CONCLUSIONS

Our findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.