Supported accommodation for people with mental health problems: the QuEST research programme with feasibility RCT

This work was produced by Killaspy et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Background Across England, around 60,000 people live in mental health supported accommodation: residential care, supported housing and floating outreach. Residential care and supported housing provide on-site support (residential care provides the highest level), whereas floating outreach staff visit people living in their own tenancies. Despite their abundance, little is known about the quality and outcomes of these services. Objectives The aim was to assess the quality, costs and effectiveness of mental health supported accommodation services in England. The objectives were (1) to adapt the Quality Indicator for Rehabilitative Care (QuIRC) and the Client Assessment of Treatment scale for use in mental health supported accommodation services; (2) to assess the quality and costs of these services in England and the proportion of people who ‘move on’ to less supported accommodation without placement breakdown (e.g. to move from residential care to supported housing or supported housing to floating outreach, or, for those receiving floating outreach, to manage with fewer hours of support); (3) to identify service and service user factors (including costs) associated with greater quality of life, autonomy and successful move-on; and (4) to carry out a feasibility trial to assess the required sample size and appropriate outcomes for a randomised evaluation of two existing models of supported accommodation. Design Objective 1 – focus groups with staff (n = 12) and service users (n = 16); psychometric testing in 52 services, repeated in 87 services (adapted QuIRC) and with 618 service users (adapted Client Assessment of Treatment scale). Objectives 2 and 3 – national survey and prospective cohort study involving 87 services (residential care, n = 22; supported housing, n = 35; floating outreach, n = 30) and 619 service users followed over 30 months; qualitative interviews with 30 staff and 30 service users. Objective 4 – individually randomised, parallel-group feasibility trial in three centres. Setting English mental health supported accommodation services. Participants Staff and users of mental health supported accomodation services. Interventions Feasibility trial involved two existing models of supported accommodation: supported housing and floating outreach. Main outcome measures Cohort study – proportion of participants who successfully moved to less supported accommodation at 30 months’ follow-up without placement breakdown. Feasibility trial – participant recruitment and withdrawal rates. Results The adapted QuIRC [QuIRC: Supported Accomodation (QuIRC-SA)] had excellent inter-rater reliability, and exploratory factor analysis confirmed its structural validity (all items loaded onto the relevant domain at the > ± 0.3 level). The adapted Client Assessment of Treatment for Supported Accommodation had good internal consistency (Cronbach’s alpha 0.89) and convergent validity (r s = 0.369; p < 0.001). Supported housing services scored higher than residential care and floating outreach on six out of seven QuIRC-SA quality domains. Service users had a high prevalence of severe self-neglect (57%) and vulnerability to exploitation (37%). Those in supported housing (25%) and floating outreach (20%) experienced more crime than those in residential care (4%) but had greater autonomy. Residential care was the most expensive service (mean cost per resident per week was £581 for residential care, £261 for supported housing and £66 for floating outreach) but supported users with the greatest needs. After adjusting for clinical differences, quality of life was similar for users of supported housing and residential care (mean difference –0.138, 95% confidence interval –0.402 to 0.126; p = 0.306), whereas autonomy was greater for supported housing users (mean difference 0.145, 95% confidence interval 0.010 to 0.279; p = 0.035). Qualitative interviews showed that staff and service users shared an understanding of service goals and what constituted effective support. After adjusting for clinical differences, those in floating outreach were more likely to move on successfully at 30 months’ follow-up than those in residential care [odds ratio (OR) 7.96; p < 0.001] and supported housing (OR 2.74; p < 0.001), and this was more likely for users of supported housing than residential care (OR 2.90; p = 0.04). Successful move-on was positively associated with scores on two QuIRC-SA domains: the degree to which the service promoted ‘human rights’ (e.g. facilitating access to advocacy) and ‘recovery-based practice’ (e.g. holding therapeutic optimism and providing collaborative, individualised care planning). Service use costs for those who moved on were significantly lower than for those who did not. Recruitment in the feasibility trial was difficult: 1432 people were screened but only eight were randomised. Barriers included concerns about accommodation being decided at random and a perceived lack of equipoise among clinicians who felt that individuals needed to ‘step down’ from supported housing to floating outreach services. Conclusions We did not find clear evidence on the most effective model(s) of mental health supported accommodation. Indeed, our feasibility study suggests that trials comparing effectiveness cannot be conducted in this country. A range of options are required to provide appropriate support to individuals with differing needs. Future work Future research in this field requires alternatives to trials. Service planners should be guided by the mental health needs of the local population and the pros and cons of the different services that our study identified, rather than purely financial drivers. Trial registration Current Controlled Trials ISRCTN19689576. Funding This programme was funded by the National Institute for Heath Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 7. See the NIHR Journals Library website for further project information. The fundholders are Camden and Islington NHS Foundation Trust and the research is a collaboration between University College London, Queen Mary University of London, King’s College London, the University of Ulster and Durham University. The research reported in this issue of the journal was funded by PGfAR as project number RP-PG-0610-10097

Thickness uniformity measurements and damage threshold tests of large-area GaAs/AlGaAs crystalline coatings for precision interferometry

Precision interferometry is the leading method for extremely sensitive measurements in gravitational wave astronomy. Thermal noise of dielectric coatings poses a limitation to the sensitivity of these interferometers. To decrease coating thermal noise, new crystalline GaAs/AlGaAs multilayer mirrors have been developed. To date, the surface figure and thickness uniformity of these alternative low-loss coatings has not been investigated. Surface figure errors, for example, cause small angle scattering and thereby limit the sensitivity of an interferometer. Here we measure the surface figure of highly reflective, substrate-transferred, crystalline GaAs/AlGaAs coatings with a custom scanning reflectance system. We exploit the fact that the reflectivity varies with the thickness of the coating. To increase penetration into the coating, we used a 1550 nm laser on a highly reflective coating designed for a center wavelength of 1064 nm. The RMS thickness variation of a two inch optic was measured to be 0.41 ± 0.05 nm. This result is within 10% of the thickness uniformity, of 0.37 nm RMS, achieved with ion-beam sputtered coatings for the aLIGO detector. We additionally measured a lower limit of the laser induced damage threshold of 64 MW/cm2 for GaAs/AlGaAs coatings at a wavelength of 1064 nm. © 2019 Optical Society of America under the terms of the OSA Open Access Publishing Agreemen

Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England.

BACKGROUND: Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10-20 % of all those with psychosis, they absorb 25-50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome. METHOD: Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care. RESULTS: Across England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients' social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00-1.08), and patients' activity (OR 1.03, 95 % CI 1.01-1.05) and social skills (OR 1.13, 95 % CI 1.04-1.24) at recruitment. CONCLUSION: Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients' social skills and activities may further enhance the effectiveness of these services

A vertical inertial sensor with interferometric readout

High precision interferometers such as gravitational-wave detectors require complex seismic isolation systems in order to decouple the experiment from unwanted ground motion. Improved inertial sensors for active isolation potentially enhance the sensitivity of existing and future gravitational-wave detectors, especially below 30 Hz, and thereby increase the range of detectable astrophysical signals. This paper presents a vertical inertial sensor which senses the relative motion between an inertial test mass suspended by a blade spring and a seismically isolated platform. An interferometric readout was used which introduces low sensing noise, and preserves a large dynamic range due to fringe-counting. The expected sensitivity is comparable to other state-of-the-art interferometric inertial sensors and reaches values of $10^{-10}\,\text{m}/\sqrt{\text{Hz}}$ at 100 mHz and $10^{-12}\,\text{m}/\sqrt{\text{Hz}}$ at 1 Hz. The potential sensitivity improvement compared to commercial L-4C geophones is shown to be about two orders of magnitude at 10 mHz and 100 mHz and one order of magnitude at 1 Hz. The noise performance is expected to be limited by thermal noise of the inertial test mass suspension below 10 Hz. Further performance limitations of the sensor, such as tilt-to-vertical coupling from a non-perfect levelling of the test mass and nonlinearities in the interferometric readout, are also quantified and discussed

Local active isolation of the AEI-SAS for the AEI 10 m prototype facility

Abstract: High precision measurements in various applications rely on active seismic isolation to decouple the experiment from seismic motion; therefore, closed feed-back control techniques such as sensor blending and sensor correction are commonly implemented. This paper reviews the active isolation techniques of the Albert Einstein Institute seismic attenuation system (AEI-SAS). Two approaches to improve the well known techniques are presented. First, the influence of the sensor basis for the signal-to-noise ratio in the chosen coordinate system is calculated and second, a procedural optimization of blending filters to minimize the optical table velocity is performed. Active isolation techniques are adapted to the mechanical properties and the available sensors and actuators of the AEI-SAS. The performance of the final isolation is presented and limitations to the isolation are analyzed in comparison to a noise model. The optical table motion reaches approximately 8 × 1 0 − 10 m / H z at 1 Hz, reducing the ground motion by a factor of approximately 100

PYKAT: Python package for modelling precision optical interferometers

PYKAT is a Python package which extends the popular optical interferometer modelling software Finesse. It provides a more modern and efficient user interface for conducting complex numerical simulations, as well as enabling the use of Python’s extensive scientific software ecosystem. In this paper we highlight the relationship between Pykat and Finesse, how it is used, and provide an illustrative example of how it has helped to better understand the characteristics of the current generation of gravitational wave interferometers.Daniel D. Brown, Philip Jones, Samuel Rowlinson, Sean Leavey, Anna C. Green, Daniel Töyrä, Andreas Freis

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

© The Author(s). 2018Background: As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales. Methods: Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses. Results: Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes. Conclusions: Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform. Trial registration: CRD42017071663Peer reviewedFinal Published versio