The BMJ Awards 2020: Mental health team of the year

Good Thinking

In the past few years, despite an increased focus on mental health, almost two thirds of those in need are not accessing mental health services and those who do, often face long waiting times.

With the launch of Good Thinking in November 2017, London became the first global city to deliver a city-wide digital mental wellbeing service. Users access the free website www.good-thinking.uk and choose an option: anxious, sleep deprived, stressed, sad, or low. They then answer three questions before being directed to relevant NHS approved apps and resources. The most popular resource is a self-assessment tool that offers more detailed information and recommendations.

It was developed through a partnership of local authorities, London’s NHS, and Public Health England and is delivered by Healthy London Partnership. It is promoted on social media, search engines, and other digital platforms. General practitioners can prescribe Good Thinking’s apps through a link from the EMIS library. By December 2019, the service had over 430 000 visits from more than 300 000 individual users

“We are trying to reach people early, where they are online, and offer something helpful whatever level of need,” says Richard Graham, consultant psychiatrist and clinical lead. “The service is available 24/7 and is accessible and private. People can access it on the bus or at 3 am when they can’t sleep and are feeling anxious.”

Supported discharge service

Around 4500 adolescents are admitted to specialist child and adolescent mental health units in England and Wales every year. However, little is known about the optimal models of care for young people presenting with urgent psychiatric needs.

A team from South London and Maudsley NHS Foundation Trust designed a randomised controlled trial to compare a supported discharge service with usual inpatient care. Local assessment liaison and outreach teams were set up, consisting of a consultant child and adolescent (CAMHS) psychiatrist, CAMHS practitioners with a nursing background, and clinical support workers.

“We offer a bespoke service tailored to the young person’s individual needs,” says Martyn Leigh, team leader. This includes psychiatric care, psychological interventions, and social support, including school reintegration. Supporting the young person’s recovery can include assertive community outreach as well as a day programme that incorporates the use of a hospital school and various therapeutic groups.

After six months, mean hospital use among patients randomised to the supported discharge programme had declined significantly—47 days compared with 84 days. Patients on the programme were also considerably less likely to have multiple self-harm and more likely to go back to school, says Dennis Ougrin, consultant psychiatrist.

The team are carrying out a further randomised controlled trial to see whether a similar support programme can prevent hospital admissions in the first place.

Local radio and mental wellbeing

Cornwall is one of the most deprived areas in the UK. Many people are farmers and are often reluctant to talk about their mental health, says Rohit Shankar, consultant in adult developmental neuropsychiatry.

A regular mental health radio phone-in programme on Radio Cornwall has helped to overcome the stigma and discrimination against people with mental health difficulties and provide valuable public education.

After a pilot programme on obsessive compulsive disorder proved successful, the programmes have run regularly since 2011. The programme, which has just had its 108th broadcast, runs once a month between 1 pm and 2 30 pm as part of the popular Laurence Reed show.

A five minute pre-recorded case study is aired during the morning. A psychiatrist and a non-medical clinician or patient expert are briefly questioned by the host, and the public are invited to ring in. Messages are also received through email and social media. A trainee psychiatrist provides an information sheet to post on the BBC website giving facts about the condition, self-help organisations, and local services.

“We have managed to shine a light on a very dark corner and make people more accepting of mental health issues,” says Shankar. “People have a chance to hear experts and know that it is OK to talk about your mental health and seek help.”

Care home assessment team

Residents in care homes account for a high number of emergency department attendances and hospital admissions. Recognising that care homes need additional support, the London borough of Enfield set up a care home assessment team (CHAT)—a fully integrated mental and physical health team including community matrons, geriatricians, a consultant psychiatrist, mental health nurses, and occupational therapists.

“One of the key elements to the programme was the input of the geriatrician, who had an allocated 16 hours a week to train up community matrons to carry out a holistic care plan for each resident,” says Carolyn Piper, mental health programme manager. The community matrons subsequently trained the care home staff to raise awareness of mental health conditions such as anxiety, dementia, and delirium as well as physical conditions and environmental triggers.

The programme resulted in a 35% reduction in emergency department attendances and non-elective admissions from the care homes, compared with a 23% increase among the non-care home population in Enfield. There was a 9% decrease in costs among those supported in the care homes, compared with a 34% increase in costs for the general population over 65 years. In addition, 39% of residents had their treatment reduced or stopped.

CHAT started as a pilot project in four homes in 2011 and currently supports 39 care homes across Enfield.

Mental health teaching for the emergency department

Patients with mental health problems can find themselves in the emergency department after expressing suicidal thoughts or behaviours, following an overdose or self-harm, or otherwise in crisis. However, emergency medicine staff have often had little exposure to mental health teaching.

All clinical members of staff should have suicide awareness training, but we found that these courses were not accessible and hard to fit into a busy schedule, says Keith McKillop, specialty doctor in emergency medicine at Queen Elizabeth University Hospital, Glasgow. He worked with a team of mental health professionals to produce training material with specific content for emergency department clinical staff and their management of patients presenting with mental health problems.

The training, which has so far been delivered to more than 400 emergency department staff members, consists of an online module, a two hour face-to-face presentation, and a follow-up questionnaire. A mental health triage assessment tool has also been updated and is now mandatory throughout the Greater Glasgow and Clyde Health Board.

“We wanted to simplify the information and work out what core things we wanted to communicate,” says McKillop. “A lot of the training is about engaging with people in crisis, de-escalating their anxiety and emotions and encouraging them to see that help and support is available to deal with their ongoing psychosocial stressors, whatever they may be.”

StayingSafe.net

Suicide is linked to self-harm, and the evidence shows that rates of self-harm are increasing. Only 50% of patients who present to emergency departments with self-harm or suicidal thoughts receive treatment compliant with National Institute for Health and Care Excellence guidelines, which includes a psychosocial assessment.

“We know there are evidence-informed interventions to reduce the risk of suicide, including safety planning, but these are not being delivered with the required amount of urgency and thoroughness,” says Alys Cole-King, clinical director of 4 Mental Health, the organisation that has developed a website with NHS England co-funding to help people struggling with suicidal thoughts.

The free website https://stayingsafe.net/ features compassionate and hopeful videos and clear information for people in distress. It includes an online safety plan that can be completed and stored on a phone or iPad. There are also sections specifically for young people and carers.

The website was designed after extensive research and input from a 200 strong expert reference group, including people who have lived experience of self-harm and suicide, health professionals, academics, and mental health activists.

Since launching in November 2018 StayingSafe.net has had 124 000 visits, and the safety plan has been downloaded or completed online 30 622 times, receiving extremely positive feedback. It has achieved an international reach and is promoted by a large number of NHS organisations, including general practices, hospitals, and third sector organisations.