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

Use of ‘acute behavioural disturbance’ in mental health records: differences over time and by ethnicity in a London NHS mental health Trust

Background Acute behavioural disturbance (ABD) is a controversial descriptor for presentations of severe agitation, aggression and physiological compromise. Aims To characterise the use of ABD-related terms in the electronic record of a large UK provider of mental health services during 2006–2021. Method The free text of all records relating to patient contacts with acute assessment mental health teams during 2006–2021 were searched for references to ABD. Identified text was coded for context of use and presence of clinical features of ABD described in the literature. Poisson regression was used to analyse differences in rates of use over time and between demographic groups. Results Mentions of ABD increased by an average of 1.12 (95% confidence interval (CI), 1.08–1.17) per year, with the greatest increase from 2019 to 2021. Black people were more than twice as likely as White people to have reference to ABD included in their assessments (rate: 2.4/1000 (95% CI 1.8–3.1) in Black people compared with 1.0/1000 (95% CI 0.8–1.3) in White people). The clinical characteristics in notes describing a current presentation of ABD rarely corresponded to those included in UK medical guidelines on ABD. Conclusions The term ABD in mental health notes appears to often, but not exclusively, be a synonym for severe agitation and conveys little meaning beyond this. However, the term's connection to a literature emphasising the high risk of physical health collapse and need for urgent treatment means that its disproportionate use in Black people may contribute to existing racial inequalities in the use of coercive measures during crisis presentations

Advance Statements for Black African and Caribbean people (AdStAC):protocol for an implementation study

Background Advance Choice Documents (ACDs) have been recommended for inclusion in new mental health legislation for England and Wales. This is based on evidence-based interventions to reduce compulsory psychiatric admission, with particular benefit for Black people, whose rates of compulsory psychiatric admission in the UK are over three times higher than those of White British people. Our aim was to explore potential barriers and enablers to effective implementation of ACDs for use by Black people with previous experience of compulsory admission. Methods Seven online and in-person workshops were held with: Black service users who had previously been compulsorily admitted, carers/supporters of Black service users, and mental health professionals. Workshops were recorded and transcribed. Results Inductive analysis was employed to identify recommendations and determine where there was a lack of consensus. Thematic analysis identified key themes of ‘people’, ‘process’ and ‘power’ pertaining to ACD implementation. Discussion Our results reinforce the need for independent facilitation for ACD creation and their potential to empower Black service users in relation to their care. They suggest that explicit acknowledgement of, and time spent listening to, the historical and individual poor experiences that underlie the treatment preferences Black people express are important aspects of ACD creation

The Representativeness of Participants With Severe Mental Illness in a Psychosocial Clinical Trial

Introduction: Cardiovascular morbidity and mortality are increased in severe mental illnesses (SMI). Trials of psychosocial health interventions to improve physical health in SMI, including in treatment-resistant schizophrenia, have shown some benefit. However, the representativeness of participants in such trials has not been determined.Method: We utilized an anonymised case register to determine if participants in a randomized controlled trial (RCT) of a novel psychosocial health intervention aiming to improve physical health in SMI had similar severity of illness to eligible non-participants. A retrospective database analysis was performed, using Health of the Nation Outcome Scale (HoNOS) data from the sample of patients participating in the IMPaCT (Improving Physical health and reducing substance use in Psychosis) RCT (n = 293) compared to all eligible participants with a psychotic illness (n = 774).Results: The mean total HoNOS score in the eligible comparator population (Mean = 9.09, SD = 5.8, range = 0–30) was significantly greater than that of the IMPaCT RCT participants (Mean = 7.16, SD = 4.7, range = 0–26), (t = 3.810, p = 0.006), as was the degree of overall illness severity and functional impairment, as measured by HoNOS.Conclusion: This study shows for the first time that the patient population participating in an RCT of a lifestyle intervention for those with SMI had a better mental health status at entry to the trial, than the total eligible population, although there was no difference in physical health needs. This has relevance to the applicability of RCTs of lifestyle interventions in service planning and suggests that when people are more unwell, greater effort may be needed to include them in psychosocial interventions. A more careful and focused recruitment approach should be followed to improve the participation of the more severely ill patients in psychosocial interventions in order to enhance the external validity of such studies

Potential gains in life expectancy from reducing amenable mortality among people diagnosed with serious mental illness in the United Kingdom.

BACKGROUND: To estimate the potential gain in life expectancy from addressing modifiable risk factors for all-cause mortality (excluding suicide and deaths from accidents or violence) across specific serious mental illness (SMI) subgroups, namely schizophrenia, schizoaffective disorders, and bipolar disorders in a Western population. METHODS: We have used relative risks from recent meta-analyses to estimate the population attribution fraction (PAF) due to specific modifiable risk factors known to be associated with all-cause mortality within SMI. The potential gain in life expectancy at birth, age 50 and age 65 years were assessed by estimating the combined effect of modifiable risk factors from different contextual levels (behavioural, healthcare, social) and accounting for the effectiveness of existing interventions tackling these factors. Projections for annual gain in life expectancy at birth during a two-decade was estimated using the Annual Percentage Change (APC) formula. The predicted estimates were based on mortality rates for year 2014-2015. RESULTS: Based on the effectiveness of existing interventions targeting these modifiable risk factors, we estimated potential gain in life expectancy at birth of four (bipolar disorders), six (schizoaffective disorders), or seven years (schizophrenia). The gain in life expectancy at age 50 years was three (bipolar disorders) or five (schizophrenia and schizoaffective disorders) years. The projected gain in life expectancy at age 65 years was three (bipolar disorders) or four (schizophrenia and schizoaffective disorders) years. CONCLUSIONS: The implementation of existing interventions targeting modifiable risk factors could narrow the current mortality gap between the general and the SMI populations by 24% (men) to 28% (women). These projections represent ideal circumstances and without the limitation of overestimation which often comes with PAFs

Outcome of a psychosocial health promotion intervention aimed at improving physical health and reducing alcohol use in patients with schizophrenia and psychotic disorders (MINT)

Background: Life expectancy is reduced by 19 years in men and 17 in women with psychosis in Sweden, largely due to cardiovascular disease. Aim: Assess whether a psychosocial health promotion intervention improves cardiometabolic risk factors, quality of life, and severity of illness in patients with psychotic disorders more than treatment as usual. Methods: A pragmatic intervention trial testing a manual-based multi-component health promotion intervention targeting patients with psychosis. The Swedish intervention was adapted from IMPaCT therapy, a health-promotion program based on motivational interviewing and cognitive behavioral therapy, designed to be incorporated into routine care. The intervention group consisted of 119 patients and a control group of 570 patients from specialized psychosis departments. Outcome variables were assessed 6 months before intervention during the run-in period, again at the start of intervention, and 12 months after the intervention began. The control group received treatment as usual. Results: The intervention had no significant effect on any of the outcome variables. However, BMI, waist circumference, systolic BP, heart rate, HbA1c, general health, and Clinical Global Impressions Scale score improved significantly during the run-in period before the start of the active intervention (observer effect). The multi-component design meant that treatment effects could only be calculated for the intervention as a whole. Conclusion: The results of the intervention are similar to those of the U.K. IMPaCT study, in which the modular health-promotion intervention had little effect on cardiovascular risk indicators. However, in the current study, the run-in period had a positive effect on cardiometabolic risk factors

Dietary intake, physical activity and sedentary behaviour patterns in a sample with established psychosis and associations with mental health symptomatology

Background People with psychosis experience cardiometabolic comorbidities, including metabolic syndrome, coronary heart disease and diabetes. These physical comorbidities have been linked to diet, inactivity and the effects of the illness itself, including disorganisation, impairments in global function and amotivation associated with negative symptoms of schizophrenia or co-morbid depression. Methods We aimed to describe the dietary intake, physical activity (PA) and sedentary behaviour patterns of a sample of patients with established psychosis participating in the Improving Physical Health and Reducing Substance Use in Severe Mental Illness (IMPaCT) randomised controlled trial, and to explore the relationship between these lifestyle factors and mental health symptomatology. Results A majority of participants had poor dietary quality, low in fruit and vegetables and high in discretionary foods. Only 29.3% completed ⩾150 min of moderate and/or vigorous activity per week and 72.2% spent ⩾6 h per day sitting. Cross-sectional associations between negative symptoms, global function, and PA and sedentary behaviour were observed. Additionally, those with more negative symptoms receiving IMPaCT therapy had fewer positive changes in PA from baseline to 12-month follow-up than those with fewer negative symptoms at baseline. Conclusion These results highlight the need for the development of multidisciplinary lifestyle and exercise interventions to target eating habits, PA and sedentary behaviour, and the need for further research on how to adapt lifestyle interventions to baseline mental status. Negative symptoms in particular may reduce patient's responses to lifestyle interventions

Effect of vitamin D supplementation on outcomes in people with early psychosis

Importance People with psychotic disorders have an increased risk of vitamin D deficiency, which is evident during first-episode psychosis (FEP) and associated with unfavorable mental and physical health outcomes. Objective To examine whether vitamin D supplementation contributes to improved clinical outcomes in FEP. Design, Setting, and Participants This multisite, double-blind, placebo-controlled, parallel-group randomized clinical trial from the UK examined adults 18 to 65 years of age within 3 years of a first presentation with a functional psychotic disorder who had no contraindication to vitamin D supplementation. A total of 2136 patients were assessed for eligibility, 835 were approached, 686 declined participation or were excluded, 149 were randomized, and 104 were followed up at 6 months. The study recruited participants from January 19, 2016, to June 14, 2019, with the final follow-up (after the last dose) completed on December 20, 2019. Interventions Monthly augmentation with 120 000 IU of cholecalciferol or placebo. Main Outcomes and Measures The primary outcome measure was total Positive and Negative Syndrome Scale (PANSS) score at 6 months. Secondary outcomes included total PANSS score at 3 months; PANSS positive, negative, and general psychopathology subscale scores at 3 and 6 months; Global Assessment of Function scores (for symptoms and disability); Calgary Depression Scale score, waist circumference, body mass index, and glycated hemoglobin, total cholesterol, C-reactive protein, and vitamin D concentrations at 6 months; and a planned sensitivity analysis in those with insufficient vitamin D levels at baseline. Results A total of 149 participants (mean [SD] age, 28.1 (8.5) years; 89 [59.7%] male; 65 [43.6%] Black or of other minoritized racial and ethnic group; 84 [56.4%] White [British, Irish, or of other White ethnicity]) were randomized. No differences were observed in the intention-to-treat analysis in the primary outcome, total PANSS score at 6 months (mean difference, 3.57; 95% CI, −1.11 to 8.25; P = .13), or the secondary outcomes at 3 and 6 months (PANSS positive subscore: mean difference, −0.98; 95% CI, −2.23 to 0.27 at 3 months; mean difference, 0.68; 95% CI, −0.69 to 1.99 at 6 months; PANSS negative subscore: mean difference, 0.68; 95% CI, −1.39 to 2.76 at 3 months; mean difference, 1.56; 95% CI, −0.31 to 3.44 at 6 months; and general psychopathology subscore: mean difference, −2.09; 95% CI, −4.36 to 0.18 at 3 months; mean difference, 1.31; 95% CI, −1.42 to 4.05 at 6 months). There also were no significant differences in the Global Assessment of Function symptom score (mean difference, 0.02; 95% CI, −4.60 to 4.94); Global Assessment of Function disability score (mean difference, −0.01; 95% CI, −5.25 to 5.23), or Calgary Depression Scale score (mean difference, −0.39; 95% CI, −2.05 to 1.26) at 6 months. Vitamin D levels were very low in the study group, especially in Black participants and those who identified as another minoritized racial and ethnic group, 57 of 61 (93.4%) of whom had insufficient vitamin D. The treatment was safe and led to a significant increase in 25-hydroxyvitamin D concentrations. Conclusions and Relevance In this randomized clinical trial, no association was found between vitamin D supplementation and mental health or metabolic outcomes at 6 months. Because so few patients with FEP were vitamin D replete, the results of this study suggest that this group would benefit from active consideration in future population health strategies. Trial Registration isrctn.org Identifier: ISRCTN1242484

Prevalence of HIV in mental health service users: a retrospective cohort study.

Objective To examine the prevalence of HIV in a cohort of people who have used secondary mental health services in the UK. Design Retrospective cohort study. Setting Routinely collected clinical data from secondary mental health services in South London, UK available for research through the Clinical Record Interactive Search tool at the National Institute for Health and Care Research Maudsley Biomedical Research Centre were matched with pseudonymised national HIV surveillance data held by the UK Health Security Agency using a deterministic matching algorithm. Participants All adults aged 16+ who presented for the first time to mental health services in the South London and Maudsley (SLaM) National Health Service Trust between 1 January 2007 and 31 December 2018 were included. Primary outcome Point prevalence of HIV. Results There were 181 177 people who had contact with mental health services for the first time between 2007 and 2018 in SLaM. Overall, 2.47% (n=4481) of those had a recorded HIV diagnosis in national HIV surveillance data at any time (before, during or after contact with mental health services), 24.73 people per 1000. HIV point prevalence was highest in people with a diagnosed substance use disorder at 3.77% (n=784). A substantial percentage of the sample did not have a formal mental health diagnosis (27%), but even with those excluded, the point prevalence remained high at 2.31%. Around two-thirds of people had their diagnosis of HIV before contact with mental health services (67%; n=1495). Conclusions The prevalence of HIV in people who have had contact with mental health services was approximately 2.5 times higher than the general population in the same geographical area. Future work should investigate risk factors and disparities in HIV outcomes between those with and without mental health service contact