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The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough. In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage. The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The \"mainstreaming\" of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.

Data from an RCT of IAPT Norway (\"Prompt Mental Health Care\" [PMHC]) were linked to several administrative registers up to five years following the intervention. The aims were to (1) examine the effects of PMHC compared to treatment-as-usual (TAU) on work-related outcomes and health care use, (2) estimate the cost-benefit of PMHC, and (3) examine whether clinical outcomes at six-month follow-up explained the effects of PMHC on work-/cost-benefit-related outcomes. RCTs with parallel assignment were conducted at two PMHC sites (N = 738) during 2016/2017. Eligible participants were considered for admission due to anxiety and/or depression. We used Bayesian estimation with 90% credibility intervals (CI) and posterior probabilities (PP) of effects in favor of PMHC. Primary outcome years were 2018-2022. The cost-benefit analysis estimated the overall economic gain expressed in terms of a benefit-cost ratio and the differences in overall public sector spending. The PMHC group was more likely than the TAU group to be in regular work without receiving welfare benefits in 2019-2022 (1.27 ≤ OR ≤ 1.43). Some evidence was found that the PMHC group spent less on health care. The benefit-cost ratio in terms of economic gain relative to intervention costs was estimated at 5.26 (90%CI - 1.28, 11.8). The PP of PMHC being cost-beneficial for the economy as a whole was 85.9%. The estimated difference in public sector spending was small. PMHC effects on work participation and cost-benefit were largely explained by PMHC effects on mental health. The results support the societal economic benefit of investing in IAPT-like services.

Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed—between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.

Objective Young adults experiencing homelessness often suffer from adverse mental health outcomes and suicide is a leading cause of death. The objective of this study is to examine service use and psychosocial risk factors for suicide, in relation to suicide risk assessment, to inform strategies for engaging youth in suicide prevention services. Methods A cross-sectional analysis of youth enrolled in a supportive housing randomized clinical trial. We categorized suicide risk into three groups (low-, moderate-, and high-risk) based on suicidal ideation and past-year suicide attempt. The service use patterns across these groups are described, as well as other psychosocial risk factors (psychiatric comorbidity, depressive symptoms, substance use, and sleep impairment). Results Among 193 enrolled youth, 126 (65.3%), 32 (16.6%), and 35 (18.1%) were categorized as low-risk, moderate-risk, and high-risk for suicide, respectively. A high proportion of youth reported ever having been diagnosed with a psychiatric disorder (57.5%) and cannabis was the most heavily used substance. However, only a minority of youth received medical care or mental health services in the past 3 months, 40% and 34%, respectively. Even fewer youth received mental/emotional health services in the past 3 months (15%), though use was highest among the high-risk group (34%). Conclusion Understanding the needs of youth experiencing homelessness who are at risk for suicide is critical to developing interventions to alleviate their risk for suicide. Given that the use of medical and mental health care is low among this population, more active outreach strategies may be warranted to deliver prevention interventions.

Background The cluster randomised trial (CRT) design is increasingly used to evaluate the impact of school-based interventions for improving social-emotional functioning outcomes in pupils. Good knowledge is required on plausible values of the intra-cluster correlation coefficient (ICC) of the outcome to calculate the required sample size in such studies. Using data from five school-based CRTs in the UK, we estimate, and describe patterns in, ICCs for social-emotional functioning outcomes. Methods Mixed effects linear regression models were fitted to estimate the ICC and variance components. Estimates for baseline data were obtained by fitting “null” models that had no predictor variables; estimates at follow-up were adjusted for trial arm status. Results Five hundred and twenty-nine (529) ICCs were estimated. Variation across clusters in the outcomes was present at the school, year group and classroom levels. Overall, the ICCs were not markedly different between the primary and secondary school settings. Most of the school- and classroom-level ICCs were less than 0.04 for pupil-reported outcomes and less than 0.035 for parent-reported outcomes; a notable exception for pupil-reported outcomes was for outcomes that reflect a common experience shared by children, such as school climate, where the ICCs were as large as 0.1. The ICCs for teacher-reported outcomes (up to 0.1 at the school level and 0.2 at the classroom level) were larger than for pupil- and parent-reported outcomes. In the CRT that allocated schools to trial arms and only sampled one classroom from each school, the nominal school-level ICCs for teacher-reported outcomes took values up to 0.25. ICCs for teacher-reported measures of internalising behaviour problems and pro-social behaviour were larger than for externalising behaviour problems. Conclusions When randomising school clusters, sub-sampling of lower-level clusters such as classrooms should be accounted for in the sample size calculation. Teacher-reported ICCs are likely to be greater than those for pupil- and parent-reported outcomes as teachers will often provide data for many or all pupils in a given school or classroom. Differences across reporter type and across outcomes need to be considered when specifying plausible values of the ICC to calculate sample size. Trial registration STARS study (ISRCTN84130388); KiVa study (ISRCTN23999021); PACES study (ISRCTN23563048); PROMISE study (ISRCTN19083628); MYRIAD study (ISRCTN86619085).

A cross-sectoral partnership was formed in 2021 in support of the recommendations in an audit on access to state-funded mental health services. In this first paper, we aimed to describe the demographic and service utilisation of adults with a mental health diagnosis in the Western Australian state-funded health system from 2005 to 2021. Inpatient, emergency department, specialised (ambulatory) community mental health service, and death records were linked in individuals aged ≥ 18 years with a mental health diagnosis in Western Australia. Altogether, 392,238 individuals with at least one mental health service contact between 1st January 2005 and 31st December 2021 were included for analysis. Females, Aboriginal and/or Torres Strait Islander people, and those who lived outside major cities or in the most disadvantaged areas were more likely to access state-funded mental health services. While the number of individuals who accessed community mental health services increased over time (from 28,769 in 2005 to 50,690 in 2021), the percentage increase relative to 2005 was notably greater for emergency department attendances (127% for emergency department; 76% for community; and 63% for inpatient). Conditions that contributed to the increase for emergency department were mainly alcohol disorder, reaction to severe stress and adjustment disorders, and anxiety disorders. Sex differences were observed between conditions. The pattern of access increased for emergency department and the community plus emergency department combination. This study confirmed that the patterns of access of state-funded mental health services have changed markedly over time and the potential drivers underlying these changes warrant further investigation.

Background Over the last 20 years governments around the world have promoted user involvement in an effort to improve the quality of health services. Despite the growing emphasis placed on user involvement in England, there is a paucity of recent studies looking at how service users and professionals perceive the outcomes of user involvement policies. This study aimed to examine the overall levels of participation in service user involvement in mental health services among professionals and service users and ascertain their views on the impact of involvement activity on various areas of service delivery. Methods A cross-sectional survey of service users and providers within community mental health services. The sampling was carried out across three mental health Trusts, two serving people living in inner-city areas and a third covering a mixed rural/urban population. A questionnaire with closed and open ended questions was used to gather the responses of service users and frontline professionals. As a mixed methods study, the analysis consisted of both quantitative and qualitative approaches. Results Three hundred and two service users responded to the survey with a response rate of 48%. One hundred and forty three frontline mental health professionals, 26.8% of those approached submitted questionnaires. Almost half of service users (N=138, 45.7%,) and healthcare professionals (N=143, 55.9%) reported having been involved in some form of user involvement activity. Although there were some differences in the responses of service users and frontline professionals, both groups reported that service user involvement was having a positive impact. Conclusions The findings show that, within the three mental health trusts examined in this study, service user involvement has become widespread and is perceived by both staff and service users to be a good policy. The study had some important limitations. The questionnaire used was based on existing literature, however it was not subjected to psychometric testing. In addition, response rates were low, particularly among professionals. Despite the limitations, the findings are encouraging, offering important of insight into views and experiences of service users and healthcare staff. Further studies are needed to assess and investigate the topic on a national level.

Background Within the context of community care, assertive community treatment (ACT) targeting individuals with severe mental disorders is typically a prolonged endeavor. Despite its extended nature, evidence on the long-term effects of ACT remains limited. This study aimed to assess the long-term effects of ACT services in Japan over 7 years by comparing readmission outcomes between the ACT and treatment-as-usual (TAU) groups. Methods This study traced participants from a prior randomized controlled trial (RCT) examining the short-term effects of ACT program in Japan. We assessed their readmission experiences, including the frequency and length (days) of readmissions over 7 years through medical record review. Multivariable analyses were conducted to examine outcomes by group. Results Of the 63 participants tracked for 7 years of follow-up (ACT group = 34, TAU group = 29), there were no significant group differences in readmission rate (TAU = 79% vs. ACT = 53%; odds ratio = 0.41, 95% CI = 0.12 to 1.35, p = 0.144) or cumulative days of hospitalization (Β = -75.66, 95% CI = -184.41 to 33.09, p  = 0.173). However, the ACT group had significantly fewer hospitalizations (Β = − 1.03, 95% CI = − 1.97 to − 0.10, p  = 0.030) than the TAU group. In particular, readmissions in the ACT group substantially decreased at 2 years after initial randomization. Conclusion In the Japanese medical landscape, an ACT program for individuals with severe mental illness might help mitigate the frequency of readmission compared with TAU over the long term. In particular, the pronounced benefits of the ACT program appear to emerge approximately 2 years after the start of ACT services. Future research in different countries is needed to confirm the findings of this study, particularly the timing at which the long-term effects of ACT services emerge for various outcomes. Trial registration The trial was retrospectively registered on 5 August 2025 with the Japan Registry of Clinical Trials (Registration number: jRCT1030250281).

IntroductionThis article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey.Methods and analysisTwo prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness.Ethics and disseminationThe two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings.Trials registration numbersNCT03571347, NCT03587896.