What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study

Background The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult – 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility – psychiatric decision units (also known as mental health decision units) – have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway. Methods Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or ‘trialability’ of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers. Discussion This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways

Adjustment with aphasia after stroke: study protocol for a pilot feasibility randomised controlled trial for SUpporting wellbeing through PEeR Befriending (SUPERB)

Background: Despite the high prevalence of mood problems after stroke, evidence on effective interventions particularly for those with aphasia is limited. There is a pressing need to systematically evaluate interventions aiming to improve wellbeing for people with stroke and aphasia. This study aims to evaluate the feasibility of a peer-befriending intervention. Methods/design: SUPERB is a single blind, parallel group feasibility trial of peer befriending for people with aphasia post-stroke and low levels of psychological distress. The trial includes a nested qualitative study and pilot economic evaluation and it compares usual care (n = 30) with usual care + peer befriending (n = 30). Feasibility outcomes include proportion screened who meet criteria, proportion who consent, rate of consent, number of missing/incomplete data on outcome measures, attrition rate at follow-up, potential value of conducting main trial using value of information analysis (economic evaluation), description of usual care, and treatment fidelity of peer befriending. Assessments and outcome measures (mood, wellbeing, communication, and social participation) for participants and significant others will be administered at baseline, with outcome measures re-administered at 4 and 10 months post-randomisation. Peer befrienders will complete outcome measures before training and after they have completed two cycles of befriending. The qualitative study will use semi-structured interviews of purposively sampled participants (n = 20) and significant others (n = 10) from both arms of the trial, and all peer befrienders to explore the acceptability of procedures and experiences of care. The pilot economic evaluation will utilise the European Quality of life measure (EQ-5D-5 L) and a stroke-adapted version of the Client Service Receipt Inventory (CSRI). Discussion: This study will provide information on feasibility outcomes and an initial indication of whether peer befriending is a suitable intervention to explore further in a definitive phase III randomised controlled trial. Trial registration: ClinicalTrials.gov identifier NCT02947776, registered 28th October 2016

What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study

Background: The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult – 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility – psychiatric decision units (also known as mental health decision units) – have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway. Methods: Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or ‘trialability’ of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers. Discussion: This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much needed information for those designing service pathways

Temperature perturbation model of the opto-galvanic effect in CO2-laser discharges

A detailed discharge model of the opto-galvanic effect in molecular laser gas mixtures is developed based on the temperature perturbation or discharge cooling mechanism of Smith and Brooks (1979). Excellent agreement between the model and experimental results in CO2 laser gas mixtures is obtained. The model should be applicable to other molecular systems where the OGE is being used for laser stabilisation and as a spectroscopic tool

Blinding participants and assessors in a feasibility randomised controlled trial of peer-befriending for people with aphasia post-stroke

Background and aims: In behavioural interventions, blinding participants to intervention versus control conditions is problematic, as is blinding assessors to participants’ group allocation. When participants are provided with information about the intervention to be tested, they will know whether they are in the intervention or the control arm of the study. This is particularly problematic in psychological interventions where people who may already be distressed or anxious are likely to become even more distressed when they realise they are in the control arm of a study. To minimise potential threats to validity and maintain lack of bias, we took a number of steps in the SUpporting well-being through PEeR-Befriending (SUPERB) feasibility trial for people with aphasia to ensure blinding. This presentation will report on these steps and evaluate their effectiveness. Methods: SUPERB is a single blind, mixed methods, parallel group phase II randomised controlled trial (RCT) comparing usual care+peer-befriending (n = 30) versus usual care (n = 30), starting at discharge from hospital. Little is known about what usual care for psychological support after stroke-aphasia constitutes, and this study will document the services the participants receive in their area for both groups. A modified two-stage consent design has been adopted (Campbell, Peters, Grant, Quilty, & Dieppe, 2005; Torgerson & Roland, 1998), as highlighted in the Medical Research Council framework for complex interventions (Craig et al., 2008). In the first stage, all participants consent to take part in a study on adjustment post-stroke and have their data collected at three time points (i.e., baseline, 4 months, and 10 months). They know they may be compared to other people in the study receiving different packages of care, but are blind to the fact that the study tests a specific intervention (peer-befriending). Following baseline assessments, participants are randomised to either usual care+peer-befriending or usual care. At this point, a second stage consent to take part in the intervention is completed with those participants allocated to the peer-befriending arm. Rate of consent at both stages is monitored. Blinded researchers (assessors) complete assessments for both groups at 4 months and 10 months. Strategies to maintain blinding of assessors include the following: the use of scripts during assessments and asking the participants not to reveal what care they have received; unblinded researcher organising post-randomisation appointments, so that assessors cannot become unblinded by partners/carers of people with aphasia revealing information; and management of the work environment (separate office space, different telephones, and no physical or electronic access to sensitive data). Instances of unblinding are recorded. Results: The trial is currently underway. Thirty-eight of 60 participants have been recruited and 27 have been randomised. The two-stage consent process has been largely successful. No instances of unblinding by participants or researchers have been recorded. Near misses (n = 4) have been recorded for the blinded researchers. These are unrelated to the assessments with participants but rather workplace factors (e.g., use of email, shared calendars, and overhearing telephone conversations). Conclusions: Blinding of participants and researchers is critical to the success of a RCT. This paper raises and discusses a range of processes including a modified two-stage consent process and careful preparation and monitoring of participants, researchers, and workplace factors – which are all important steps to reducing the possibility of unblinding

Wireless communication with chaos

Peer reviewedPublisher PD

“For them and for me”: a qualitative exploration of peer befrienders’ experiences supporting people with aphasia in the SUPERB feasibility trial

Peer-befriending, where support is offered by someone with shared lived experience, is an intervention that may facilitate successful adjustment in people experiencing post-stroke aphasia. This paper explores the experiences of the peer-befrienders. People with aphasia were recruited as peer-befrienders within the SUPERB trial investigating befriending for people with post-stroke aphasia. The intervention comprised six visits over three months. Peer-befrienders were matched with at least one befriendee and received training and ongoing supervision. They were invited to participate in in-depth interviews which were analysed using framework analysis. All 10 befrienders participated in interviews, reporting on 19 matches. Seven main themes emerged: content of the sessions; befriender-befriendee relationship; negotiating the visits; handling boundaries and endings; positive impact of the befriending for befrienders and befriendees; and beliefs about the nature and value of peer support. While befrienders described challenges, such as negotiating journeys and witnessing distress, the role was perceived as a "secure challenge" due to the support and training received. Befrienders perceived the role as enjoyable and rewarding, and felt they were making a positive difference. They were unanimous in believing that people with aphasia can offer unique and valuable support to others with aphasia. ClinicalTrials.gov identifier NCT02947776, registered 28th October 2016.Implications for rehabilitationPeople with lived experience of stroke and aphasia were able to offer emotional and social peer support to others with aphasia within the SUPERB trial.Although there were challenges, peer befrienders perceived the role as rewarding and satisfying.Peer befrienders valued the training and ongoing supervision and support they received to deliver the intervention.It is recommended that rehabilitation professionals considering offering peer-befriending schemes provide training and ongoing supervision to support peer-befrienders fulfil their role, as well as practical support with, e.g., arranging visits

“Loneliness can also kill:” a qualitative exploration of outcomes and experiences of the SUPERB peer-befriending scheme for people with aphasia and their significant others

People with aphasia post-stroke are at risk for depression and social isolation. Peer-befriending from someone with similar experiences may promote wellbeing and provide support. This paper explored the views of people with aphasia and their significant others about peer-befriending. We conducted a qualitative study within a feasibility trial (SUPERB) on peer-befriending for people with post-stroke aphasia and low levels of distress. Of the 28 participants randomised to the intervention, semi-structured in-depth interviews were conducted with 10 purposively selected people with aphasia (at both 4- and 10-months post-randomisation) and five of their significant others (at 4-months). Interviews were analysed using Framework Analysis. Participants and their significant others were positive about peer-befriending and identified factors which influenced their experience: the befrienders' personal experience of stroke and aphasia, their character traits and the resulting rapport these created, the conversation topics they discussed and settings they met in, and the logistics of befriending, including planning visits and negotiating their end. Interviewees also made evaluative comments about the befriending scheme. Peer-befriending was an acceptable intervention. Benefits for emotional wellbeing and companionship were reported. The shared experience in the befriending relationship was highly valued.Implications for RehabilitationThe lived experience of stroke and aphasia of befrienders was highly valued by people with aphasia receiving peer-befriending.Training, regular supervision, and support for befrienders with practicalities such as organising visits ensured the befriending scheme was perceived as straightforward and acceptable by befriendees.Those receiving peer-befriending would recommend it to others; they found it beneficial, especially in terms of emotional wellbeing and companionship

‘Emotion is of the essence. … Number one priority’: A nested qualitative study exploring psychosocial adjustment to stroke and aphasia

Background: Stroke and aphasia can have a profound impact on people’s lives, and depression is a common, frequently persistent consequence. Social networks also suffer, with poor social support associated with worse recovery. It is essential to support psychosocial wellbeing post-stroke, and examine which factors facilitate successful adjustment to living with aphasia. Aims: In the context of a feasibility randomised controlled trial of peer-befriending (SUPERB), this qualitative study explored adjustment for people with aphasia in the post-acute phase of recovery, a phase often neglected in previous research. Method and procedures: Semi-structured interviews were conducted with 20 people with aphasia and ten significant others, who were purposively sampled from the wider group of 56 people with aphasia and 48 significant others. Interviews took place in participants homes; they were analysed using Framework Analysis. Outcomes and results: Participants with aphasia were 10 women and 10 men; their median (IQR) age was 70 (57.5-77). Twelve participants had mild aphasia, eight moderate-severe. Significant others were six women and four men with a median (IQR) age of 70.5 (43-79). They identified a range of factors that influenced adjustment to aphasia post-stroke. Some were personal resources, including: mood and emotions; identity/sense of self; attitude and outlook; faith and spirituality; moving forward. Significant others also talked about the impact of becoming carers. Other factors were external sources of support, including: familial and other relationships; doctors, nurses and hospital communication; life on the ward; therapies and therapists; psychological support, stroke groups and community and socialising. Conclusions and implications: To promote adjustment in the acute phase, hospital staff should prioritise the humanising aspects of care provision. In the post-acute phase, clinicians play an integral role in supporting adjustment and can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy

Supporting wellbeing through peer-befriending (SUPERB) for people with aphasia: A feasibility randomised controlled trial

Objective: To determine the feasibility and acceptability of peer-befriending, for people with aphasia. Design: Single-blind, parallel-group feasibility randomised controlled trial comparing usual care to usual care + peer-befriending. Participants and setting: People with aphasia post-stroke and low levels of distress, recruited from 5 NHS Hospitals and linked community services; their significant others; and 10 befrienders recruited from community. Intervention: Six 1-hour peer-befriending visits over three months. Main measures: Feasibility parameters included proportion eligible of those screened; proportion consented; missing data; consent and attrition rates. Acceptability was explored through qualitative interviews. Outcomes for participants and significant others were measured at baseline, 4- and 10-months; for peer-befrienders before training and after one/two cycles of befriending. Results: Of 738 patients identified, 75 were eligible of 89 fully screened (84%), 62 consented (83% of eligible) and 56 randomised. Attrition was 16%. Adherence was high (93% attended ⩾2 sessions, 81% all six). The difference at 10 months on the GHQ-12 was 1.23 points on average lower/better in the intervention arm (95% CI 0.17, −2.63). There was an 88% decrease in the odds of GHQ-12 caseness (95% CI 0.01, 1.01). Fourty-eight significant others and 10 peer-befrienders took part. Procedures and outcome measures were acceptable. Serious adverse events were few ( n = 10, none for significant others and peer-befrienders) and unrelated. Conclusions: SUPERB peer-befriending for people with aphasia post-stroke experiencing low levels of distress was feasible. There was preliminary evidence of benefit in terms of depression. Peer-befriending is a suitable intervention to explore further in a definitive trial. Clinical trial registration-URL: http://www.clinicaltrials.gov Unique identifier: NCT02947776 Subject terms: Translational research, mental health, rehabilitation, quality and outcomes, strok