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High resource expenditure on acute care is a challenge for mental health services aiming to focus on supporting recovery, and relapse after an acute crisis episode is common. Some evidence supports self-management interventions to prevent such relapses, but their effect on readmissions to acute care following a crisis is untested. We tested whether a self-management intervention facilitated by peer support workers could reduce rates of readmission to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis. We did a randomised controlled superiority trial recruiting participants from six crisis resolution teams in England. Eligible participants had been on crisis resolution team caseloads for at least a week, and had capacity to give informed consent. Participants were randomly assigned to intervention and control groups by an unmasked data manager. Those collecting and analysing data were masked to allocation, but participants were not. Participants in the intervention group were offered up to ten sessions with a peer support worker who supported them in completing a personal recovery workbook, including formulation of personal recovery goals and crisis plans. The control group received the personal recovery workbook by post. The primary outcome was readmission to acute care within 1 year. This trial is registered with ISRCTN, number 01027104. 221 participants were assigned to the intervention group versus 220 to the control group; primary outcome data were obtained for 218 versus 216. 64 (29%) of 218 participants in the intervention versus 83 (38%) of 216 in the control group were readmitted to acute care within 1 year (odds ratio 0·66, 95% CI 0·43–0·99; p=0·0438). 71 serious adverse events were identified in the trial (29 in the treatment group; 42 in the control group). Our findings suggest that peer-delivered self-management reduces readmission to acute care, although admission rates were lower than anticipated and confidence intervals were relatively wide. The complexity of the study intervention limits interpretability, but assessment is warranted of whether implementing this intervention in routine settings reduces acute care readmission. National Institute for Health Research.

\"Trauma-Informed Practices with Children and Adolescents is a sourcebook of practical approaches to working with children and adolescents that synthesizes research from leading trauma specialists and translates it into easy-to-implement techniques. The approaches laid out address the sensory and somatic experiences of trauma within structured formats that meet the \"best practices\" criteria for trauma informed care: safety, self-regulation, trauma integration, healthy relationships, and healthy environments. Each chapter contains short excerpts, case examples, and commentary relevant to the chapter topic from recognized leaders in the field of trauma intervention with children and adolescents. In addition to this, readers will find chapters filled with easily applied activities, methods, and approaches to assessment, self-regulation, trauma integration, and resilience-building. The book's structured yet comprehensive approach provides professionals with the resources they need to help trauma victims not just survive but thrive and move from victim thinking to survivor thinking using the current best practices in the field\"--Provided by publisher.

Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care. To evaluate a 1-year programme to improve CRTs' model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233). Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated. All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI -1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes. The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

People with dementia frequently experience mental health crisis requiring psychiatric hospital admission. In the UK, Teams Managing Crisis in Dementia (TMCDs) vary in structure and practice due to the absence of a standardized model. A pragmatic, randomised controlled trial (RCT) was designed to evaluate the AQUEDUCT Best Practice Tool and online Resource Kit (RK). Twenty-three TMCDs across England were randomised 1:1 To receive the RK plus usual care (intervention) or usual care alone (control) ( www.isrctn.com/ISRCTN42855694 ). The primary outcome was the number of psychiatric hospital admissions for people with dementia at the primary endpoint of six months. Secondary outcomes included TMCD staff mental health (GHQ-12), psychological flexibility (WAAQ), and work engagement (UWES); and for people with dementia and carers, service satisfaction (CSQ-8) and mental wellbeing (GHQ-12). There was no significant difference in number of psychiatric admissions between groups (incident rate ratio: 0.74; 95% CI: 0.37-1.48; p  = 0.397) and the primary endpoint was met. No significant differences were found for the secondary outcomes across staff or service user groups. Fidelity to the intervention varied; five TMCDs met or exceeded implementation criteria, while others reported structural barriers. Limited engagement was attributed to the absence of a learning collaborative and pandemic-related service pressures. Although the RK was valued by staff for guiding quality improvement, it did not significantly reduce hospital admissions or improve secondary outcomes. Future studies should prioritise implementation support and explore systemic barriers to service improvement in dementia crisis care. This study found no significant impact of the AQUEDUCT Best Practice Resource Kit on psychiatric hospital admissions for people with dementia, highlighting implementation challenges and the need for further evaluation.

Unhealthy alcohol use among young adults is a major public health concern. Brief motivational interventions for young adults in the Emergency Department (ED) have shown promising but inconsistent results. Based on the literature on brief intervention and motivational interviewing efficacy and active ingredients, we developed a new motivational intervention model for young adults admitted in the ED with alcohol intoxication. Using an iterative qualitative design, we first pre-tested this model by conducting 4 experimental sessions and 8 related semi-structured interviews to evaluate clinicians' and patients' perceptions of the intervention's acceptability and feasibility. We then conducted a consultation meeting with 9 international experts using a nominal group technique. The intervention model was adjusted and finally re-tested by conducting 6 new experimental sessions and 12 related semi-structured interviews. At each round, data collected were analyzed and discussed, and the intervention model updated accordingly. Based on the literature, we found 6 axes for developing a new model: High level of relational factors (e.g. empathy, alliance, avoidance of confrontation); Personalized feedback; Enhance discrepancy; Evoke change talk while softening sustain talk, strengthen ability and commitment to change; Completion of a change plan; Devote more time: longer sessions and follow-up options (face-to-face, telephone, or electronic boosters; referral to treatment). A qualitative analysis of the semi-structured interviews gave important insights regarding acceptability and feasibility of the model. Adjustments were made around which information to provide and how, as well as on how to deepen discussion about change with patients having low levels of self-exploration. The experts' consultation addressed numerous points, such as information and advice giving, and booster interventions. This iterative, multi-component design resulted in the development of an intervention model embedded in recent research findings and theory advances, as well as feasible in a complex environment. The next step is a randomized controlled trial testing the efficacy of this model.

Background Although telemental health can make suicide prevention treatments more scalable and accessible, limited evidence demonstrates successful reductions in suicidality when interventions are administered through telehealth platforms. To address this limitation, the current work investigated the effects of two suicide prevention treatments – a clinician-guided Crisis Response Plan and a self-guided Safety Planning approach. Methods After completing the screening process, 82 participants with high suicide ideation and/or a lifetime history of suicidal behavior were randomly assigned across the two groups. Trained research clinicians administered the interventions using a videoconferencing platform. After the intervention delivery was complete, participants reported the therapeutic alliance they experienced with their clinician using an online survey. Participants also reported their overall suicidality 45 days after receiving the intervention. In addition, participants’ perceived usefulness of the received intervention and actual use of the plan were recorded. Linear and logistic regression models predicted how suicidality, perceived utility, and actual use of their intervention protocols varied depending on the high (Crisis Response Plan) versus low (self-guided Safety Planning) level of clinician-led collaboration the two treatments entailed. Results Both Crisis Response Plan and self-guided Safety Planning were found to lower suicidality after receiving them via telehealth services. At the same time, those who received the Crisis Response Plan (the more collaborative form of therapy) reported experiencing a stronger therapeutic alliance with the clinician, utilizing the plan more often and perceiving it as more useful. These findings demonstrate the additional benefits of adopting a more collaborative approach because of its effectiveness and perceived utility, which has implications for suicide-related distress reduction in the short and long term. Conclusions Evidence from this randomized control trial suggests that Crisis Response Plan is a suitable candidate for delivering suicide prevention via telehealth platform because of its effectiveness in reducing suicidality and its collaborative approach to building a strong therapeutic alliance, perceived usefulness, and actual utility in everyday life. Trial registration This paper was part of a registered RCT: https://clinicaltrials.gov/study/NCT04888845 . Registration date: Date: 2021-04-22.

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Current Controlled Trials ISRCTN 93681536.

Background People with serious mental health problems (SMHP) are more likely to be admitted to psychiatric hospital following contact with crisis services. Admissions can have significant personal costs, be traumatic and are the most expensive form of mental health care. There is an urgent need for treatments to reduce suicidal thoughts and behaviours and reduce avoidable psychiatric admissions. Methods A multi-stage, multi-arm (MAMS) randomised controlled trial (RCT) with four arms conducted over two stages to determine the clinical and cost effectiveness of three psychosocial treatments, compared to treatment as usual (TAU), for people with SMHP who have had recent suicidal crisis. Primary outcome is any psychiatric hospital admissions over a 6-month period. We will assess the impact on suicidal thoughts and behaviour, hope, recovery, anxiety and depression. The remote treatments delivered over 3 months are structured peer support (PREVAIL); a safety planning approach (SAFETEL) delivered by assistant psychologists; and a CBT-based suicide prevention app accessed via a smartphone (BrighterSide). Recruitment is at five UK sites. Stage 1 includes an internal pilot with a priori progression criteria. In stage 1, the randomisation ratio was 1:1:1:2 in favour of TAU. This has been amended to 2:2:3 in favour of TAU following an unplanned change to remove the BrighterSide arm following the release of efficacy data from an independent RCT. Randomisation is via an independent remote web-based randomisation system using randomly permuted blocks, stratified by site. An interim analysis will be performed using data from the first 385 participants from PREVAIL, SAFETEL and TAU with outcome data at 6 months. If one arm is dropped for lack of benefit in stage 2, the allocation ratio of future participants will be 1:1. The expected total sample size is 1064 participants (1118 inclusive of BrighterSide participants). Discussion There is a need for evidence-based interventions to reduce psychiatric admissions, via reduction of suicidality. Our focus on remote delivery of established brief psychosocial interventions, utilisation of different modalities of delivery that can provide sustainable and scalable solutions, which are also suitable for a pandemic or national crisis context, will significantly advance treatment options. Trial registration ISRCTN33079589. Registered on June 20, 2022.

IntroductionDespite expert recommendations to prioritise non-invasive and patient-centred approaches for behavioural crisis management, physical restraints are commonly used in the emergency department (ED). Patients describe the restraint process as coercive and dehumanising. The use of peer support workers, who are individuals with lived experience of mental illness and behavioural conditions, has shown positive patient outcomes when assisting individuals experiencing behavioural crises. However, there is limited evidence of the implementation of such an approach in the ED setting. The goal of this study is to evaluate if the implementation of a Peer support enhanced Agitation Crisis response Team (PACT) for behavioural crisis management in the ED is more effective than usual care to reduce restraint use and improve outcomes among patients presenting to the ED with behavioural crises.Methods and analysisWe will first conduct a stakeholder-informed needs assessment to codesign the protocol and then train staff and peers in PACT intervention readiness. Next, a stepped-wedge, cluster-randomised controlled trial will be conducted over 3 years at five ED sites across a healthcare system in the Northeast USA. The PACT intervention will integrate peer delivery of trauma-informed care within a structured, interprofessional, team-based response protocol for behavioural crisis management. The primary outcome is the rate of physical restraint and/or sedation use. The secondary outcome is the level of patient agitation during the ED visit. Analyses of primary and secondary outcomes will be conducted using generalised linear mixed models.Ethics and disseminationThis protocol has been approved by the Yale University Human Investigation Committee (protocol number 2000037554). The study is deemed minimal risk and has been granted a waiver of consent for trial participants. However, verbal consent will be obtained for a subset of patients receiving follow-up data collection. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations, or through direct mail notifications.Trial registration numberClinicaltrials.gov: NCT06556069.