What’s specific about the nature of mental health difficulties in students and how can this inform treatment?

This thesis explores how mental health service provision in university settings could be adapted to better meet the needs of students with mental health disorders. A systematic review and meta-analysis was conducted to assess the effectiveness of psychological interventions in student populations with, or at risk of, mental health disorders. The impact of adapting interventions for the particular needs of university students was also explored. Next, a cross-sectional survey of university students was conducted to explore differences in preferences for sources of support, and consider whether these may differ between international and UK resident students. Qualitative interviews and a confirmatory focus group further explored students’ experience of mental health support while at university, and provided preliminary ideas for the types of changes in services that students would hope to see. Finally, analyses were conducted using a large dataset of people who use National Health Service (NHS) psychological therapies: outcomes were compared between students and adults of the same age who were employed using multivariate logistic regression analyses. For the student population only, the association between changes on measures of social functioning and treatment outcomes was also explored using Growth Mixture Model analysis. Together, the research suggests that the adaptation of current service provision to consider a number of additional student-specific factors contributing to mental health difficulties could usefully be applied in both university mental health services and NHS psychological services. Improved integration of support across these two settings could also significantly contribute to improved university student well-being and mental health

The association between social class and the impact of treatment for mental health problems:a systematic review and narrative synthesis

PURPOSE: This systematic review aimed to synthesise all quantitative literature on the association between social class and the effectiveness of interventions for mental health disorders. METHODS: Systematic literature searches (inception-March 2021) were conducted across 7 databases, and all quantitative studies meeting inclusion criteria, examining the impact of social class on access to treatment, or intervention effectiveness, or the impact of treatment on social mobility, were synthesised narratively. RESULTS: Evidence suggests that lower social class may be associated with reduced access to primary and secondary mental health care and increased likelihood of access via crisis services, and patients of lower social class may not benefit from all mental health interventions, with reduced effectiveness. While limited, there was some indication that psychosocial interventions could encourage increased employment rates. CONCLUSION: Social class is associated with the effectiveness of psychological interventions, and should be considered when designing new interventions to prevent barriers to access and improve effectiveness

The association between trajectories of change in social functioning and psychological treatment outcome in university students: a growth mixture model analysis

BACKGROUND: The transition to university and resultant social support network disruption can be detrimental to the mental health of university students. As the need for mental health support is becoming increasingly prevalent in students, identification of factors associated with poorer outcomes is a priority. Changes in social functioning have a bi-directional relationship with mental health, however it is not clear how such measures may be related to effectiveness of psychological treatments. METHODS: Growth mixture models were estimated on a sample of 5221 students treated in routine mental health services to identify different trajectories of change in self-rated impairment in social leisure activities and close relationships during the course of treatment. Multinomial regression explored associations between trajectory classes and treatment outcomes. RESULTS: Five trajectory classes were identified for social leisure activity impairment while three classes were identified for close relationship impairment. In both measures most students remained mildly impaired. Other trajectories included severe impairment with limited improvement, severe impairment with delayed improvement, and, in social leisure activities only, rapid improvement, and deterioration. Trajectories of improvement were associated with positive treatment outcomes while trajectories of worsening or stable severe impairment were associated with negative treatment outcomes. CONCLUSIONS: Changes in social functioning impairment are associated with psychological treatment outcomes in students, suggesting that these changes may be associated with treatment effectiveness as well as recovery experiences. Future research should seek to establish whether a causal link exists to understand whether integrating social support within psychological treatment may bring additional benefit for students

Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation:a systematic review, meta-analysis, and narrative synthesis

BACKGROUND: Use of involuntary psychiatric hospitalisation varies widely within and between countries. The factors that place individuals and populations at increased risk of involuntary hospitalisation are unclear, and evidence is needed to understand these disparities and inform development of interventions to reduce involuntary hospitalisation. We did a systematic review, meta-analysis, and narrative synthesis to investigate risk factors at the patient, service, and area level associated with involuntary psychiatric hospitalisation of adults. METHODS: We searched MEDLINE, PsycINFO, Embase, and the Cochrane Controlled Clinical Register of Trials from Jan 1, 1983, to Aug 14, 2019, for studies comparing the characteristics of voluntary and involuntary psychiatric inpatients, and studies investigating the characteristics of involuntarily hospitalised individuals in general population samples. We synthesised results using random effects meta-analysis and narrative synthesis. Our review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is registered on PROSPERO, CRD42018095103. FINDINGS: 77 studies were included from 22 countries. Involuntary rather than voluntary hospitalisation was associated with male gender (odds ratio 1·23, 95% CI 1·14-1·32; p<0·0001), single marital status (1·47, 1·18-1·83; p<0·0001), unemployment (1·43, 1·07-1·90; p=0·020), receiving welfare benefits (1·71, 1·28-2·27; p<0·0001), being diagnosed with a psychotic disorder (2·18, 1·95-2·44; p<0·0001) or bipolar disorder (1·48, 1·24-1·76; p<0·0001), and previous involuntary hospitalisation (2·17, 1·62-2·91; p<0·0001). Using narrative synthesis, we found associations between involuntary psychiatric hospitalisation and perceived risk to others, positive symptoms of psychosis, reduced insight into illness, reduced adherence to treatment before hospitalisation, and police involvement in admission. On a population level, some evidence was noted of a positive dose-response relation between area deprivation and involuntary hospitalisation. INTERPRETATION: Previous involuntary hospitalisation and diagnosis of a psychotic disorder were factors associated with the greatest risk of involuntary psychiatric hospitalisation. People with these risk factors represent an important target group for preventive interventions, such as crisis planning. Economic deprivation on an individual level and at the population level was associated with increased risk for involuntary hospitalisation. Mechanisms underpinning the risk factors could not be identified using the available evidence. Further research is therefore needed with an integrative approach, which examines clinical, social, and structural factors, alongside qualitative research into clinical decision-making processes and patients' experiences of the detention process. FUNDING: Commissioned by the Department of Health and funded by the National Institute of Health Research (NIHR) via the NIHR Mental Health Policy Research Unit

Are students less likely to respond to routinely delivered psychological treatment? A retrospective cohort analysis

BACKGROUND: Depression and anxiety disorders are increasingly prevalent among university students, making the provision of effective treatment in this population a priority. Whilst campus-based services provide some psychological treatments, many students are treated by routine adult psychological treatment services which have no focus or adaptations to treatment for student populations. We aimed to compare psychological treatment outcomes between university students and young adults (aged 18-25) in employment to explore whether routinely delivered psychological interventions are equally effective for these groups, or whether students report poorer outcomes. METHODS: A retrospective cohort was formed of 19,707 patients treated by eight National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) services in England. Associations between student status (compared to same-age employed adults) and psychological treatment outcomes were explored using logistic regression models. Models were adjusted for important treatment, clinical and demographic characteristics, and propensity score matching was used to explore the robustness of effects. RESULTS: Students and the employed comparison group were similar on baseline characteristics at assessment, but students were less likely to reliably recover (OR = 0.90 [95% CI = 0.83;0.96]) and reliably improve (OR = 0.91 [95% CI = 0.84;0.98]) by the end of treatment in fully adjusted models. Students and the employed group did not differ regarding the likelihood of deterioration (OR = 0.89 [95% CI = 0.78;1.02]) or treatment dropout (OR = 1.01 [95% CI = 0.93;1.11]). CONCLUSIONS: Students appear at risk of poorer outcomes compared to employed younger adults when treated in routine psychological treatment services. Students may require additional support and treatment adaptations that account for student-specific stressors as this might improve psychological treatment outcomes

Current state of the evidence on community treatments for people with complex emotional needs:a scoping review

BACKGROUND: Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN. METHODS: We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020. RESULTS: We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services. CONCLUSIONS: Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group

Development of a conceptual framework to guide description and evaluation of social interventions for people with serious mental health conditions

People with serious mental health conditions face social exclusion and have poorer social outcomes compared to the general population in several areas of life. Social exclusion also negatively impacts mental health. Promising models of support to improve social outcomes for people with serious mental health conditions have been described in the literature and proliferate in practice, but typologies of support are not clearly established and a robust evidence base for effective approaches is lacking in many areas. We conducted a scoping review of relevant literature and consulted with experts in the field to identify models to improve social circumstances across eight life domains, with the aim of developing a conceptual framework to distinguish the main broad approaches to improving the social circumstances of people with serious mental health conditions. We also sought to explore which approaches have been used in models within each life domain. This work was conducted in collaboration with a group of expert stakeholders, including people with lived experience of accessing mental health services. We developed a conceptual framework which distinguishes sources and types of support, allowing description of complex interventions to improve the social circumstances of people with serious mental health problems, and providing a framework to guide future service development and evaluation

An exploration of flavours in studies of e‐cigarettes for smoking cessation: secondary analyses of a systematic review with meta‐analyses

Aims: To estimate associations between e-cigarette flavour and smoking cessation and study product use at 6 months or longer. Methods: Secondary analysis of data from a living systematic review, with meta-analyses and narrative synthesis, incorporating data up to Jan 2022. Included studies provided people who smoked combustible cigarettes with nicotine e-cigarettes for the purpose of smoking cessation, compared with no treatment or other stop smoking interventions. Measurements included smoking cessation and study product use at 6 months or longer reported as risk ratios (RR) with 95% confidence intervals (CI); flavour use at any time points. Results: We included 16 studies (n=10,336); 14 contributed to subgroup analyses and 10 provided participants with a choice of e-cigarette flavour. We judged nine, five and two studies at high, low, and unclear risk of bias, respectively. Subgroup analyses showed no clear associations between flavour and cessation or product use. In all but one analysis tests for subgroup differences resulted in I2 values between 0% and 35%. In the comparison between nicotine e-cigarettes and nicotine replacement therapy (NRT) (I2 =65.2% for subgroup differences), studies offering tobacco flavour e-cigarettes showed evidence of a greater proportion of participants still using at six-months or longer (RR=3.81; 95% CI=1.45 to 10.05; 3 studies; n=1181; I2 =84%), whereas there was little evidence for greater 6-month use when studies offered a choice of flavours (RR=1.44; 95% CI=0.80 to 2.56; 2 studies; n=454; I2 =82%). However, substantial statistical heterogeneity within subgroups makes interpretation of this result unclear. In the 10 studies where participants had a choice of flavours and this was tracked over time some switching between flavours occurred, but there were no clear patterns in flavour preferences. Conclusions: There does not appear to be a clear association between e-cigarette flavours and smoking cessation or longer-term e-cigarette use, possibly due to a paucity of data. There is evidence that people using e-cigarettes to quit smoking switch between e-cigarette flavours

Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis

BACKGROUND: Poor social circumstances can induce, exacerbate and prolong symptoms of mental health conditions, while having a mental health condition can also lead to worse social outcomes. Many people with mental health conditions prioritise improvement in social and functional outcomes over reduction in clinical symptoms. Interventions that improve social circumstances in this population should thus be considered a priority for research and policy. METHODS: This rapid evidence synthesis reports on randomised controlled trials of interventions to improve social circumstances across eight social domains (Housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship) in people with mental health conditions. Economic evaluations were also identified. A comprehensive, stepped search approach of the Cochrane library, MEDLINE, Embase, PsycINFO, Web of Science and Scopus was conducted. RESULTS: One systematic review and 102 randomised controlled trials were included. We did not find RCT evidence for interventions to improve family, intimate and caring relationships and only one or two trials for each of improving money and basic needs, victimisation and exploitation, and rights, inclusion and citizenship. Evidence from successful interventions in improving homelessness (Housing First) and employment (Individual Placement and Support) suggests that high-intensity interventions which focus on the desired social outcome and provide comprehensive multidisciplinary support could influence positive change in social circumstances of people with mental health conditions. Objective social isolation could be improved using a range of approaches such as supported socialisation and social skills training but interventions to reduce offending showed few benefits. Studies with cost and cost-effectiveness components were generally supportive of interventions to improve housing and vocational outcomes. More research is needed to ensure that social circumstances accompanied by high risks of further exacerbation of mental health conditions are adequately addressed. CONCLUSIONS: Although there is a large body of literature examining how to support some aspects of life for people with mental health conditions, more high-quality evidence is required in other social domains. Integration into mental health services of interventions targeting social circumstances could significantly improve a number of social outcomes

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps