Sleep problems and referral intentions in mental health services: service user self-report and staff proxy report surveys

BACKGROUND

Sleep problems are common in mental health service users, but few non-pharmacological therapies are offered. Therapies are being developed and tested, but there may be barriers to these therapies reaching those who need them.

METHODS

Light-Dark and Activity Rhythm Therapy (L-DART), is a new sleep therapy delivered by an occupational therapist, which has been feasibility tested in people with schizophrenia spectrum diagnoses. This paper presents two surveys, conducted with mental health staff and service users, on sleep problems, treatment wishes; and barriers and facilitators to uptake of L-DART or similar therapies. Descriptive statistics, single-level and multi-level ordinal logistic regression were used to examine factors associated with sleep problems and referral intentions.

FINDINGS

Sleep problems were commonly identified by staff and service users, there was demand for non-pharmacological intervention across diagnostic and demographic categories, but staff readiness to refer differed according to NHS Trust and service user diagnosis. Staff and service user reports differed in awareness of sleep disordered breathing and parasomnias, and wish for referral. Staff were more confident identifying sleep problems than addressing them, but more training was associated with greater confidence concerning both assessment and treatment.

CONCLUSIONS

A range of sleep problems are prevalent and recognised in mental health service users, and there is an unmet need for non-pharmacological sleep interventions. Improving suitable resources to support self-management in this group may help; Staff and service users also reported a high readiness to refer or be referred for sleep interventions. Staff training to improve identification of sleep problems, and differentiation between types of sleep problems, would support access to the most appropriate treatments.

Developing an Intervention to Improve Occupational Participation for Justice-Involved People with a Personality Disorder: Defining and Describing Intervention Components

Occupational participation is undertaking personally meaningful and socially valued activities and roles. It is an important outcome for health and justice interventions, as it is integral to health and desistance. We report the third of a four-stage research project to develop an intervention to improve occupational participation for justice-involved people with a personality disorder in the community. We completed a Delphi survey to produce expert consensus on intervention components and their content, ascertain participant ratings of 28 factors for their level of influence on occupational participation, and the modifiability of the factors with this population. Thirty multi-disciplinary participants completed three survey rounds. Most factors were rated very influential, but few were considered easily modifiable. Participants agreed 121 statements describing intervention components and content. Twenty-seven statements did not reach consensus. In targeting specific factors in intervention, practitioners must balance their degree of influence with potential modifiability. The results will inform intervention manualization and modeling.

Identifying priorities, directions and a vision for Indigenous mental health using a collaborative and consensus-based facilitation approach

Background

Mental health disparities between Indigenous and non-Indigenous people in Canada are related to underlying economic, social, and political inequities that are legacies of colonization and the oppression of Indigenous cultures. It also widely acknowledged that mental health services currently available may not be culturally appropriate in supporting the health needs of Indigenous Canadians. A two-day Indigenous mental health forum examined mental health needs and gaps among Indigenous communities across the Regional Municipality of Wood Buffalo (RMWB) on Treaty 8 territory, in northern Alberta, Canada. This paper outlines the insights generated by stakeholder engagement at the forum to identify and prioritize directions for Indigenous mental health and build a vision and strategy for improving mental health services and programs for the region’s diverse Indigenous population.

Methods

We applied a modified nominal group technique (NGT) consensus method embedded within Indigenous knowledge to determine key priorities and directions for Indigenous-focused mental health and synthesize information from discussions that occurred at the forum. Following the NGT, a participatory community visioning exercise was conducted with participants to develop a vision, guiding principles, and components of an action plan for an Indigenous mental health strategy for the RMWB.

Results

Four key themes for setting priorities and directions for Indigenous mental health emerged from roundtable group discussions: 1) understand the realities of mental health experiences for Indigenous peoples, 2) design a holistic and culturally rooted mental health system, 3) foster cross-sectoral engagement and collaboration on mental health service delivery, and 4) focus on children and youth. The community visioning exercise helped stakeholders to visualize a direction or path forward for addressing existing gaps in the mental health system and opportunities for strengthening Indigenous mental health in the region.

Conclusions

Forum participants described mental health and well-being around holistic concepts of social and emotional well-being. Addressing Indigenous mental health and wellness involves multi-sectoral action in various settings including community and school through programs, policies, and other interventions that promote mental health for all Indigenous peoples, as well as for those at greater risk such as children and youth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07682-3.

Virtual reality in social skills training programs for people with schizophrenia: A systematic review and focus group

Introduction

This study aims to determine the guidelines for the design of a social skills training programme for people with schizophrenia using virtual reality.

Methods

This article encompasses two studies: Study 1, a systematic review of five articles indexed in the databases B-on, PubMed, Clinical trials and Cochrane Library (2010–2020); Study 2, a focus group of occupational therapists trained in mental health and multimedia professionals, in which they discussed the outline of such a programme.

Results

A set of guidelines were identified as central and consensual which should be included in the programme. It must have multilevel logic and gradual learning, with simulations of everyday situations, in which it is possible to practise the skills of conversation and communication. Virtual reality provides people with schizophrenia with unlimited opportunities, enhancing a personalized intervention.

Conclusion

Social skills training could be part of the treatment for people with schizophrenia, and virtual reality is a promising tool to complement traditional training, although still little implemented in mental health services. Occupational therapists have a prominent role in the development and application of this because of their knowledge of activity analysis and their ability to facilitate the generalization of skills in different contexts.

A systematic review into the effectiveness of occupational therapy for improving function and participation in activities of everyday life in adults with a diagnosis of depression

BACKGROUND

Depression is a common mental health disorder, the symptoms of which can disrupt functioning and lead to reduced participation in everyday activities.  Occupational therapy is routinely provided for people with such difficulties; however, the evidence underpinning this intervention for depression has yet to be systematically assessed.

METHOD

A systematic review of the effectiveness of occupational therapy for people with a diagnosis of depression, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was undertaken. Seven databases were searched using terms for depression combined with terms associated with occupational therapy. Due to heterogeneity in study design and outcome measures, a best evidence synthesis was undertaken as an alternative to meta-analysis.

RESULTS

Of 1962 articles identified, 63 full texts were assessed and six met the inclusion criteria. Studies were carried out in Canada, Germany, the Netherlands, Taiwan and the United Kingdom. There was strong evidence for the effectiveness of occupational therapy return-to-work interventions for improving depression symptomology, limited evidence for occupational therapy lifestyle interventions for reducing anxiety and suicidal ideation, and limited evidence for improving work participation.  No studies evaluated individualised client-centred occupational therapy, highlighting a gap in research.

LIMITATIONS

Incomplete reporting within studies and heterogeneity prevented meta-analysis.  English language restrictions were applied.

CONCLUSIONS

Whilst overall the evidence base for occupational therapy for depression is limited, strong evidence was found for the effectiveness of occupational therapy return-to-work interventions, which is important given the costs associated with mental ill-health and work absence. Further research is needed to strengthen the evidence base.

Occupational therapy delivered by specialists versus non-specialists for people with schizophrenia

BACKGROUND

Schizophrenia is a severe mental health condition that is characterised by positive symptoms, such as hallucinations and delusions; negative symptoms, such as flattened affect, thought disorder (disrupted speech), and lack of motivation; and cognitive symptoms, such as problems with memory and attention. Schizophrenia can occur as an isolated episode, or as a recurring cycle of remission and relapse, and is associated with impairment in psychosocial and occupational functioning.Although antipsychotic drugs are the main treatment for people with schizophrenia, in most countries mental health services usually provide a range of add-on interventions, including occupational therapy. This is a complex intervention designed to support and enable continued participation in daily life through engagement in activities and occupations meaningful to the individual. Occupational therapists are professionals trained to deliver therapy where the emphasis is on improving occupational function and participation rather than treating symptoms, and uses a wide range of methods based on the needs of individuals. However, similar interventions may also be delivered by staff not trained as occupational therapists.

OBJECTIVES

To examine the effects of occupational therapy delivered by occupational therapists compared to occupational therapy delivered by any other person for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including trial registers) on 4 November 2016 and 26 July 2018.

SELECTION CRITERIA

All randomised controlled trials evaluating the functional or clinical outcomes of occupational therapy, or both, for people with schizophrenia delivered by occupational therapists compared with occupational therapy for people with schizophrenia delivered by anyone other than occupational therapists.

DATA COLLECTION AND ANALYSIS

Review authors independently inspected citations, selected studies, extracted data, and appraised study quality.

MAIN RESULTS

The search yielded 1633 records. Of these, we retrieved 17 full-text reports (14 studies) for further scrutiny, which we subsequently excluded as they did not meet our inclusion criteria.

AUTHORS' CONCLUSIONS

Currently there are no randomised controlled trials comparing delivery of occupational therapy for people diagnosed with schizophrenia by occupational therapists with delivery of similar interventions by anyone other than occupational therapists. Research studies employing methodologically robust trial designs are needed to establish whether or not there are better outcomes for people with a diagnosis of schizophrenia with occupational therapy that is delivered by trained occupational therapists.

A cluster randomised controlled trial of a staff-training intervention in residential units for people with long-term mental illness in Portugal: the PromQual trial

PURPOSE

This study aimed to assess the efficacy of a staff-training intervention to improve service users' engagement in activities and quality of care, by means of a cluster randomised controlled trial.

METHOD

All residential units with at least 12-h a day staff support (n = 23) were invited to participate. Quality of care was assessed with the Quality Indicator for Rehabilitative Care (QuIRC) filled online by the unit's manager. Half the units (n = 12) were randomly assigned to continue providing treatment as usual, and half (n = 11) received a staff-training intervention that focused on skills for engaging service users in activities, with trainers working alongside staff to embed this learning in the service. The primary outcome was service users' level of activity (measured with the Time Use Diary), reassessed at 4 and 8 months. Secondary outcomes were the quality of care provided (QuIRC), and service users' quality of life (Manchester Short Assessment of Quality of Life) reassessed at 8 months. Generalized linear mixed effect models were used to assess the difference in outcomes between units in the two trial arms. The trial was registered with Current Controlled Trials (Ref NCT02366117).

RESULTS

Knowledge acquired by the staff during the initial workshops increased significantly (p ≤ 0.01). However, the intervention and comparison units did not differ significantly in primary and secondary outcomes at either follow-up.

CONCLUSIONS

The intervention increased the level of knowledge of staff without leading to an improvement in service users' engagement in activities, quality of life, or quality of care in the units.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Background

The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap.

Methods

The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses.

Results

Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study.

Conclusions

People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery.

Main limitation

Our programme included only NHS, non-secure, inpatient mental health rehabilitation services.

Trial registration

Current Controlled Trials ISRCTN25898179.

Funding

The NIHR Programme Grants for Applied Research programme.

Occupational therapists as change agents in multidisciplinary teams

Introduction

This qualitative study explored the experiences of occupational therapists attempting to implement change within multidisciplinary teams via a 5-week training intervention. This encouraged ward staff in inpatient mental health rehabilitation units to facilitate service user engagement in activities. This study is supplementary to a randomised control trial (RCT).

Method

Daily diaries and training reflections completed by two therapists (P1 and P2) during the training were subjected to Framework analysis. The indexing stage of this process was completed in collaboration with the participants.

Findings

When implementing change, the occupational therapists encountered a number of barriers such as emotional responses and attitudes towards service users. Facilitators of change included openness, sharing knowledge and skills, and reported change. The analysis revealed a change process moving from ‘assessing the context’, to ‘building relationships’ and ‘addressing issues’ that was aided by the therapists’ high-level skills and capacity for social and self-awareness.

Conclusion

The process of change aligned well with the chosen three-stage model of change as well as occupational therapy philosophy. When acting as change agents, the therapists adapted and applied their clinical skills to the organisational context in accord with their core values and capacity for social and self-awareness.

Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients' engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial

BACKGROUND

Mental health inpatient rehabilitation services focus on people with complex psychosis who have, for example, treatment-refractory symptoms, cognitive impairment, and severe negative symptoms, which impair functioning and require lengthy admission. Engagement in activities could lead to improvement in negative symptoms and function, but few trials have been done. We aimed to investigate the effectiveness of a staff training intervention to increase patients' engagement in activities.

METHODS

We did a single-blind, two-arm, cluster-randomised controlled trial in 40 mental health inpatient rehabilitation units across England. Units were randomly allocated to either a manual-based staff training programme delivered by a small intervention team (intervention group, n=20) or standard care (control group, n=20). The primary outcome was patients' engagement in activities 12 months after randomisation, measured with the time use diary. With this measure, both the degree of engagement in an activity and its complexity are recorded four times a day for a week, rated on a scale of 0-4 for every period (maximum score of 112). Analysis was by intention-to-treat. Random-effects models were used to compare outcomes between study groups. Cost-effectiveness was assessed by combining service costs with the primary outcome. This study is registered with Current Controlled Trials (ISRCTN25898179).

FINDINGS

Patients' engagement in activities did not differ between study groups (coefficient 1·44, 95% CI -1·35 to 4·24). An extra £101 was needed to achieve a 1% increase in patients' engagement in activities with the study intervention.

INTERPRETATION

Our training intervention did not increase patients' engagement in activities after 12 months of follow-up. This failure could be attributable to inadequate implementation of the intervention, a high turnover of patients in the intervention units, competing priorities on staff time, high levels of patients' morbidity, and ceiling effects because of the high quality of standard care delivered. Further studies are needed to identify interventions that can improve outcomes for people with severe and complex psychosis.

FUNDING

National Institute for Health Research.

Developing Mental Health Occupational Therapy Practice to Meet the Needs of People with Mental Health Problems and Physical Disability

It is well documented and evidenced that individuals with serious mental illness have an increased risk of developing a range of physical illnesses and conditions. This practice analysis describes how an initial audit of mental health occupational therapists identified a lack of clarity and protocols around working with individuals with associated physical conditions. Local joint care pathways and a skills development programme were introduced, and a follow-up audit completed to assess progress to date. The advancement in practice and production of a clear physical care pathway has made a positive difference to service users.

Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users' engagement in activities

BACKGROUND

This study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this.

METHODS/DESIGN

This study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users' engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a "hands-on", manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care.

DISCUSSION

The study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).

Occupational therapy for people with psychotic conditions in community settings: a pilot randomized controlled trial

OBJECTIVES

To investigate the effectiveness of a long established intervention, occupational therapy for people with psychotic conditions, and to inform future research designs.

DESIGN

A pilot randomized controlled trial.

SETTING

Two community mental health teams in a UK city.

PARTICIPANTS

Forty-four adults with schizophrenia or other psychotic conditions, and functional problems.

INTERVENTIONS

Twelve months of individualized occupational therapy in community settings, as an adjunct to usual care and compared to treatment as usual. A two to one randomization ratio was used in favour of occupational therapy.

OUTCOME MEASURES

Social Functioning Scale, Scale for the Assessment of Negative Symptoms and employment.

RESULTS

Both groups' scores on Social Functioning Scale and Scale for the Assessment of Negative Symptoms showed significant improvement over 12 months. The Social Functioning Scale overall mean difference for occupational therapy was 2.33, P=0.020 and for treatment as usual was 6.17, P=0.023. The Scale for the Assessment of Negative Symptoms total mean difference for occupational therapy was -16.25, P<0.001 and for treatment as usual was -17.36, P= 0.011. There were no differences between the two groups on any of the outcome measures. After 12 months the occupational therapy group showed clinically significant improvements that were not apparent in the control group. These were in four subscales of the Social Functioning Scale: relationships, independence performance, independence competence and recreation. Out of 30 people receiving occupational therapy those with a clinical level of negative symptoms reduced from 18 (64%) to 13 (46%), P=0.055.

CONCLUSION

This pilot study suggested that individualized occupational therapy may contribute to recovery but more focus is recommended on people's cognitive abilities and employment.

Occupational Therapy Defined as a Complex Intervention: A 5-Year Review

This paper describes the review of the impact of the College of Occupational Therapists' publication, Occupational therapy defined as a complex intervention (Creek 2003). The background to the publication is outlined briefly. The method of data collection and the descriptive-explanatory method of data analysis are described.

The three main findings are presented: occupational therapists have continued to access the definition throughout the 5 years since it was published; the definition has been read and used both in the United Kingdom and in other countries; and the definition is understood and used in a variety of different ways and for different purposes. The paper concludes that the definition of occupational therapy as a complex intervention captured a major shift in how occupational therapists understand the world, but that this way of thinking needs to be embedded more fully into all pre-registration and post-registration education programmes.