Collaborative care intervention for individuals with severe mental illness: the PARTNERS2 programme including complex intervention development and cluster RCT

Background and aims: Individuals living with severe mental illness such as schizophrenia and bipolar can have significant emotional, cognitive, physical and social challenges. Most people with severe mental illness in the United Kingdom do not receive specialist mental health care. Collaborative care is a system of support that combines clinical and organisational components to provide integrated and person-centred care. It has not been tested for severe mental illness in the United Kingdom. We aimed to develop and evaluate a primary care-based collaborative care model (PARTNERS) designed to improve quality of life for people with diagnoses of schizophrenia, bipolar or other psychoses when compared with usual care. Methods: Phase 1 included studies to (1) understand context: an observational retrospective study of primary and secondary care medical records and an update of the Cochrane review ‘Collaborative care approaches for people with severe mental illness’; (2) develop and formatively evaluate the PARTNERS intervention: a review of literature on collaborative care and recovery, interviews with key leaders in collaborative care and recovery, focus groups with service users and a formative evaluation of a prototype intervention model; and (3) develop trial science work in this area: a core outcome set for bipolar and recruitment methods. In phase 2 we conducted a cluster randomised controlled trial measuring quality of life using the Manchester Short Assessment of Quality of Life and secondary outcomes including time use, recovery and mental well-being; a cost-effectiveness study; and a mixed-methods process evaluation. Public involvement underpinned all of the workstream activity through the study Lived Experience Advisory Panel and the employment of service user researchers in the project team. Results phase 1: The study of records showed that care for individuals under secondary care is variable and substantial and that people are seen every 2 weeks on average. The updated Cochrane review showed that collaborative care interventions were highly variable, and no reliable conclusions can be drawn about effectiveness. The PARTNERS model incorporated change at organisational, practitioner and individual levels. Coaching was selected as the main form of support for individuals’ personal goals. In the formative evaluation, we showed that more intensive supervision and ‘top-up’ training were needed to achieve the desired shifts in practice. A core outcome set was developed for bipolar, and measures were selected for the trial. We developed a stepped approach to recruitment including initial approach and appointment. Results phase 2: The trial was conducted in four areas. In total, 198 participants were recruited from 39 practices randomised. Participants received either the PARTNERS intervention or usual care. The follow-up rate was 86% at 9–12 months. The mean change in overall Manchester Short Assessment Quality of Life score did not differ between the groups [0.25 (standard deviation 0.73) for intervention vs. 0.21 (standard deviation 0.86) for control]. We also found no difference for any secondary measures. Safety outcomes (e.g. crises) did not differ between those receiving and those not receiving the intervention. Although the costs of intervention and usual care were similar, there is insufficient evidence to draw conclusions about the overall cost-effectiveness of PARTNERS. The mixed-methods process evaluation demonstrated that a significant proportion of individuals did not receive the full intervention. This was partly due to care partner absence and participant choice. The in-depth realist informed case studies showed that participants generally appreciated the support, with some describing having a ‘professional friend’ as very important. For some people there was evidence that delivery of the intervention had led to specific personal changes. Strengths and limitations: The phase 1 records study provided insights into usual care that had not been previously documented. The realist informed complex intervention development was both theoretical and pragmatic. The trial continued through the COVID-19 pandemic with high levels of follow-up. The process evaluation had the depth to explore individual changes in participants’ response to the intervention. Weaknesses in the trial methodology included suboptimal implementation, outcome measures that may not have been sensitive to changes patients most appreciated and difficulties collecting some outcomes. Conclusions: While PARTNERS was not shown to be superior to usual care, the change to PARTNERS care was not shown to be unsafe. Full intervention implementation was challenging, but this is to be expected in studies of care that include those with psychosis. Some individuals responded well to the intervention when psychological support in the form of individualised goal setting was flexibly deployed, with evidence that having access to a ‘professional friend’ was experienced as particularly helpful for some individuals. Future work: Key components of the PARTNERS model could be developed further and tested, along with improved supervision in the context of ongoing community mental health care change. Trial registration: This trial is registered as ISRCTN95702682

Evaluation of a primary care-based collaborative care model (PARTNERS2) for people with diagnoses of schizophrenia, bipolar, or other psychoses: study protocol for a cluster randomised controlled trial

BackgroundCurrent NHS policy encourages an integrated approach to provision of mental and physical care for individuals with long term mental health problems. The ‘PARTNERS2’ complex intervention is designed to support individuals with psychosis in a primary care setting.AimThe trial will evaluate the clinical and cost-effectiveness of the PARTNERS2 intervention.Design & settingThis is a cluster randomised controlled superiority trial comparing collaborative care (PARTNERS2) with usual care, with an internal pilot to assess feasibility. The setting will be primary care within four trial recruitment areas: Birmingham & Solihull, Cornwall, Plymouth, and Somerset. GP practices are randomised 1:1 to either (a) the PARTNERS2 intervention plus modified standard care (‘intervention’); or (b) standard care only (‘control’).MethodPARTNERS2 is a flexible, general practice-based, person-centred, coaching-based intervention aimed at addressing mental health, physical health, and social care needs. Two hundred eligible individuals from 39 GP practices are taking part. They were recruited through identification from secondary and primary care databases. The primary hypothesis is quality of life (QOL). Secondary outcomes include: mental wellbeing, time use, recovery, and process of physical care. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action, and look for unintended consequences. An economic evaluation will estimate its cost-effectiveness. Intervention delivery and follow-up have been modified during the COVID-19 pandemic.ConclusionThe overarching aim is to establish the clinical and cost-effectiveness of the model for adults with a diagnosis of schizophrenia, bipolar, or other types of psychoses

Abstracts from the NIHR INVOLVE Conference 2017

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Sedimentary macrofossil records reveal ecological change in English lakes: implications for conservation

Aquatic macrophytes play a key role in providing habitat, refuge and food for a range of biota in shallow lakes. However, many shallow lakes have experienced declines in macrophyte vegetation in recent decades, principally due to eutrophication. As changes in macrophyte composition and abundance can affect overall ecological structure and function of a lake, an assessment of the timing and nature of such changes is crucial to our understanding of the wider lake ecosystem. In the typical absence of historical plant records, the macro-remains of macrophytes preserved in lake sediments can be used to assess long-term changes in aquatic vegetation. We generated recent (150–200 years) plant macrofossil records for six English lakes subject to conservation protection to define past macrophyte communities, assess trajectories of ecological change and consider the implications of our findings for conservation targets and strategies. The data for all six lakes reveal a diverse submerged macrophyte community, with charophytes as a key component, in the early part of the sedimentary records. The stratigraphies indicate considerable change to the aquatic vegetation over the last two centuries with a general shift towards species more typically associated with eutrophic conditions. A common feature is the decline in abundance of low-growing charophytes and an increase in tall canopy-forming angiosperms such as fine-leaved Potamogeton species, Zannichellia palustris and Callitriche species. We hypothesise, based on findings from long-term datasets and palaeoecological records from enriched shallow lakes where plants are now absent, that the observed shifts provide a warning to managers that the lakes are on a pathway to complete macrophyte loss such that nutrient load reduction is urgently needed. It is the sound understanding of present-day plant ecology that affords such reliable interpretation of the fossil data which, in turn, provide valuable context for current conservation decisions

Polymer field-effect transistors

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Polymer field-effect transistors

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Defining Seasonal Functional Traits of a Freshwater Zooplankton Community Using δ13C and δ15N Stable Isotope Analysis

Functional-based approaches are increasingly being used to define the functional diversity of aquatic ecosystems. In this study, we proposed the use of δ13C and δ15N stable isotopes as a proxy of zooplankton functional traits in Lake Maggiore, a large, deep subalpine Italian lake. We analyzed the seasonal pattern of δ13C and δ15N signatures of different crustacean zooplankton taxa to determine food sources, preferred habitats, and trophic positions of species throughout one year. The cladocerans Daphnia longispina galeata gr., Diaphanosoma brachyurum, and Eubosmina longispina were grouped into a primary consumer functional group from their δ13C and δ15N isotopic signatures, but while the former two species shared the same food sources, the latter exhibited a more selective feeding strategy. Cyclopoid copepods occupied a distinct functional group from the other secondary consumers, being the most 15N enriched group in the lake. The δ15N signature of calanoid copepods showed trophic enrichment in comparison to Daphnia and Eubosmina and linear mixing model results confirmed a predator-prey relationship. In our study, we have demonstrated that the use of δ13C and δ15N stable isotopes represented an effective tool to define ecological roles of freshwater zooplankton species and to determine functional diversity in a lake

Back to the future: using palaeolimnology to infer long-term changes in shallow lake food webs

1. Shallow lakes are often cited as classic examples of systems that exhibit trophic cascades but, whilst they provide good model systems with which to test general ecological theory and to assess long-term community change, their food web linkages have rarely been resolved. 2. We sought to redress this, and to demonstrate the potential benefits of integrating palaeolimnological and contemporary data, by constructing highly resolved food webs for the extant communities of two shallow U.K. lakes from different positions along a gradient of eutrophication. The surface sediment cladoceran and submerged macrophyte assemblages in the less enriched site, Selbrigg Pond, matched the palaeolimnological assemblages of the more enriched site, Felbrigg Hall Lake, in the 1920s. Thus, Selbrigg was a temporal analogue for Felbrigg, from which the consequences of long-term eutrophication on food web structure could be inferred. These data represent the first steps towards reconstructing not just past assemblages (i.e. nodes within a food web), but also past interactions (i.e. links within a food web): a significant departure from much of the previous research in palaeolimnology. 3. We found that, in line with theoretical predictions, the structure of the food web changed in the latter stages of eutrophication. Not only were species lost, but so were the interconnections between them, so that the network collapsed into a simpler, less reticulate state. This structural change, which was associated with a greater channelling of energy through a smaller number of nodes as alternative feeding pathways disappear, could lead to reduced dynamic stability, pushing the network towards further simplification. Our data suggested that these changes were linked to reductions in the spatial extent of submerged vegetation and a shift from a benthic towards a more pelagic-dominated system, as the plant-associated subweb eroded over time. 4. Although these data are among the first of their kind, the palaeo-analogue approach used here demonstrates the huge potential for applying food web theory to understand how and why these ecological networks undergo dramatic changes during eutrophication. Furthermore, because of the rich biological record preserved in their sediments, shallow lakes represent potentially important models for examining long-term intergenerational dynamics, thereby providing a means by which models and data can be integrated on meaningful timescales – a goal that has long proved elusive in food web ecology