Housing First (HF), a recovery-oriented approach, was proven effective in stabilising housing situations of homeless individuals with severe mental disorders, yet had limited effectiveness on recovery outcomes on a short-term basis compared to standard treatment. The objective was to assess the effects of the HF model among homeless people with high support needs for mental and physical health services on recovery, housing stability, quality of life, health care use, mental symptoms and addiction issues on 4 years of data from the Un Chez Soi d'Abord trial.

A multicentre randomised controlled trial was conducted from August 2011 to April 2018 with intent-to-treat analysis in four French cities: Lille, Marseille, Paris and Toulouse. Participants were homeless or precariously-housed patients with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia. Two groups were compared: the HF group (n = 353) had immediate access to independent housing and support from the assertive community treatment team; the Treatment-As-Usual (TAU) group (n = 350) had access to existing support and services. Main outcomes were personal recovery (Recovery Assessment Scale (RAS) scale), housing stability, quality of life (S-QoL), global physical and mental status (Medical Outcomes Study 36-item Short Form Health Survey (SF-36)), inpatient days, mental symptoms (Modified Colorado Symptom Index (MCSI)) and addictions (Mini International Neuropsychiatric Interview (MINI) and Alcohol Use Disorders Identification Test (AUDIT)). Mixed models using longitudinal and cluster designs were performed and adjusted to first age on the street, gender and mental disorder diagnosis. Models were tested for time × group and site × time interactions.

The 703 participants [123 (18%) female] had a mean age of 39 years (95% CI 38.0–39.5 years). Both groups improved RAS index from baseline to 48 months, with no statistically significant changes found between the HF and TAU groups over time. HF patients exhibited better autonomy (adjusted β = 2.6, 95% CI 1.2–4.1) and sentimental life (2.3, 95% CI 0.5–4.1), higher housing stability (28.6, 95% CI 25.1–32.1), lower inpatient days (−3.14, 95% CI −5.2 to −1.1) and improved SF-36 mental composite score (−0.8, 95% CI −1.6 to −0.1) over the 4-year follow-up. HF participants experienced higher alcohol consumption between baseline and 48 months. No significant differences were observed for self-reported mental symptoms or substance dependence.

Data at 4 years were consistent with 2-year follow-up data: similar improvement in personal recovery outcomes but higher housing stability, autonomy and lower use of hospital services in the HF group compared to the TAU group, with the exception of an ongoing alcohol issue. These sustained benefits support HF as a valuable intervention for the homeless patients with severe mental illness.

ClinicalTrials.gov identifier: NCT01570712

To investigate the reasons behind difficulties in recruiting patients to randomized controlled trials (RCTs) in psychiatry and to examine a database of RCTs for differences between studies in mental health and other specialities.

A discussion of recent changes in research governance in the UK and Europe followed by an examination of the database of all trials supported by the Health Technology Assessment programme of the National Institute of Health Research in the UK between 1993 and 2007 to determine if three different measures, (i) time between grant approval and study start date, (ii) percentage of additional time given to extend recruitment and (iii) percentage of planned recruitment achieved, changed over the time period studied and differed between mental health, cancer and other medical disciplines.

Despite attempts in the UK to accelerate the process of clinical trials in recent years, there was a significant increase in the extension time for trials to be completed (p = 0.038) and the percentage of planned recruitment to mental health studies (71%) was significantly less than for cancer (90.3%) and other studies (86.1%) (p = 0.032).

These results suggest that, despite the priority afforded to the advancement of RCTs in healthcare, such studies are encountering increasing difficulty in recruiting to time and target. We suggest that this difficulty can be attributed, at least in part, to the excessively byzantine regulation and governance processes for health research in the UK, and unnecessary bureaucracy in the current National Health Service system. Mental health studies appear particularly vulnerable to delay and better systems to facilitate recruitment are required urgently for the evidence base to be improved and facilitate new cost-effective interventions.

Increasing therapeutic inpatient activities may improve the quality and outcomes of care. Evaluation of these interventions is necessary including assessment of cost-effectiveness. The aim of this paper is to describe the development and reliability of a tool to collect information on care contacts and therapeutic activities of patients on inpatient wards.

The development of the tool consisted of: 1) literature review, 2) interviews with staff, 3) expert consultation, 4) feasibility study, 5) focus groups with staff members, and 6) reliability tests. Service use data were collected with the tool and costs calculated.

Service users' reported more use of activities than that contained in case notes during a 7-day period. This resulted in a cost difference of £10 per person. Case notes had more one-to-one nursing contacts, with a cost difference of £4 per person. One-day data showed less nurse contact time reported by participants compared to observational data (p < 0.001) but similar use of activities. Costs were £46 for the tool and £67 for the observational data.

This tool is a good source of information on the number of activities attended by service users and contacts with psychiatrists. There is some disagreement with other sources of information on interactions between service users and nurses, possibly reflecting different definitions of a ‘meaningful contact’. This does not have a major impact on cost given that for much of the care received there is reasonable agreement.

To investigate the spatial distribution of self-harm incidence rates, their socioeconomic correlates and sex/age differences using data on self-harm presentations to emergency departments from The Manchester Self-Harm Project (2003–2013).

Smoothed standardised incidence ratios for index self-harm episodes (n = 14 771) and their associations with area-level socioeconomic factors across 258 small areas (median population size = 1470) in the City of Manchester municipality were estimated using Bayesian hierarchical models.

Higher numbers and rates of self-harm were found in the north, east and far southern zones of the city, in contrast to below average rates in the city centre and the inner city zone to the south of the centre. Males and females aged 10–24, 25–44 and 45–64 years showed similar geographical patterning of self-harm. In contrast, there was no clear pattern in the group aged 65 years and older. Fully adjusted analyses showed a positive association of self-harm rates with the percentage of the unemployed population, households privately renting, population with limiting long-term illness and lone-parent households, and a negative association with the percentage of ethnicity other than White British and travel distance to the nearest hospital emergency department. The area-level characteristics investigated explained a large proportion (four-fifths) of the variability in area self-harm rates. Most associations were restricted to those aged under 65 years and some associations (e.g. with unemployment) were present only in the youngest age group.

The findings have implications for allocating prevention and intervention resources targeted at high-risk groups in high incidence areas. Targets for area-based interventions might include tackling the causes and consequences of joblessness, better treatment of long-term illness and consideration of the accessibility of health services.

Persistent inequalities exist in how individuals from minority ethnic groups access mental health care. A failure to investigate how these inequalities are experienced and what they mean to people with psychosis has privileged professional narratives and hindered our understanding of how they are sustained and what could be done to reduce them. The aim of this study was to investigate the long-term experience of living with psychosis and navigating mental health services within different ethnic groups.

Our approach was informed by work on narrative analysis and prioritised the meaning that mental health services held for participants. In-depth interviews with 17 black Caribbean, 15 white British and 3 non-British white people with psychosis as part of AESOP-10, a 10-year follow-up of an ethnically diverse cohort of individuals with first-episode psychosis in the UK. Thematic narrative analysis was used to examine experiences at the personal level within and then across the individual accounts.

Service users shared many defining experiences and narratives frequently returned to individuals' first contact with mental health services, first hospital admission, the experience of impatient wards, and the meaning of medication and diagnosis in their lives. We found that experiences of powerlessness punctuated the journey through mental health services and this appeared to dominate the accounts of black Caribbean, and to a lesser extent, white British participants. The findings reveal how negative expectations and experiences of mental health services are compounded over time, creating a vicious cycle of disempowerment and mistrust that manifests for many in resistance to – or at the best passive acceptance of – intervention by mental health services. High levels of need, coupled with alienation from services, contributed to negative patterns of service use among black Caribbean participants. White participants recounted substantial, though fewer, experiences of disempowerment and more instances of shared decision making that for some helped protect positive aspects of their lives.

Against a background of entrenched social and economic disempowerment, services were experienced as disempowering by many black Caribbean people, compounding and perpetuating a sense of alienation. Concerted efforts by services to more systematically target social needs and to share power through partnership working may reduce the mistrust that many with psychosis feel when entering services and in turn reduce persistent inequalities across ethnic groups.

Previous cross-sectional studies revealed inconsistent results regarding mental health treatment preferences among the general population. In particular, it is unclear to what extent specific age groups approve psychotherapy or psychotropic medication for the treatment of mental disorders. We explore whether treatment recommendations of either psychotherapy or psychiatric medication change over the lifespan which includes age-related effects due to increasing age of a person, cohort effects that reflect specific opinions during the time a person was born and period effects that reflect societal changes.

Using data from three identical population surveys in Germany from 1990, 2001 and 2011 (combined n = 9046), we performed age-period-cohort analyses to determine the pure age, birth cohort and time period effects associated with the specific treatment recommendations for a person with either depression or schizophrenia, using logistic Partial Least-Squares regression models.

For both disorders, approval of both psychotherapy and medication for a person with mental illness increases with age. At the same time, younger cohorts showed stronger recommendations particularly for psychotherapy (OR around 1.07 per decade). The strongest effects could be observed for time period with an increase in recommendation between 1990 and 2001 with odds ratio of 2.36 in depression and 2.97 in schizophrenia, respectively. In general, the treatment option that showed the strongest increase in recommendation was medication for schizophrenia and psychotherapy for depression.

Underutilisation of psychotherapy in old age seems not to reflect treatment preferences of older persons. Thus, special treatment approaches need to be offered for this group that seems to be willing for psychotherapy but do not yet use it. Cohort patterns suggest that approval of psychotherapy among older persons will likely further increase in the coming years as these people get older. Finally, strong period effects underpin the importance of changing attitudes in the society. These could reflect reporting changes about psychiatric topics in the media or a general increase in the perception of treatment options. Nevertheless, more treatment offers especially for older people are needed.