Background: The use of health data from sources such as administrative and medical records to examine efficacy of health interventions is becoming increasingly common. Addressing selection bias inherent in these data is important; treatments are allocated according to clinical need and resource availability rather than delivered under experimental conditions. Propensity score (PS) methods are widely used to address selection bias due to observed confounding. This project used PS methods with observational cohort data relating to individuals who had attended an Emergency Department (ED) following self-harm (including self-poisoning and self-injury). This group is at greatly increased risks of further self-harm, suicide and all-cause mortality compared to the general population. However, it is not clear how hospital management affects risks of these adverse outcomes. Methods: A systematic review of PS methods with record-based mental health care data was used to determine the most appropriate methodological approach to estimate treatment effects following presentation to ED following self-harm. Following this review, PS stratification and PS matching methods were used with observational self-harm data to address observed baseline differences between patients receiving different types of clinical management following their hospital presentation (specialist psychosocial assessment, medical admission, referral to outpatient mental health services and psychiatric admission). Effects on repeat attendance for self-harm, suicide and all-cause mortality within 12 months were estimated. Advice on the interpretation and dissemination of results was sought from service users. Results: The systematic review resulted in 32 studies. The quality of the implementation and reporting of methods was mixed. Sensitivity analysis of the potential impacts of unobserved confounding was largely absent from the studies. Results from analysis of the self-harm cohorts showed that, broadly, prior to PS adjustment, individuals receiving each of the four categories of hospital management had higher risks of repeat attendance for self-harm, suicide and all-cause mortality than those not receiving that management. The use of PS methods resulted in attenuation of most of these increased risks. Psychosocial assessment appeared to be associated with reduced risk of repeat attendance for self-harm (risk ratio 0.87, 95% CI 0.80 to 0.95). Three advisors attended a group meeting and a further two provided responses by email. As a result of advisors' recommendations, an information sheet is being developed containing information about what patients can expect when attending hospital following self-harm and how treatment might influence future risk. Conclusions: Propensity score methods are a promising development in evaluating routine care for individuals who have self-harmed. There is now more robust evidence that specialist psychosocial assessment is beneficial in reducing risk of further attendances for self-harm. Advisors offered different perspectives to the researchers, leading to novel suggestions for dissemination.

Heart failure is a chronic disease and a common cause of hospitalizations and readmissions within 30-days of discharge. To decrease the cost of care for patients with heart failure, the Centers for Medicare and Medicaid Services initiated the Readmissions Reduction Program that reduces payment to hospitals with preventable readmissions. Among the causes for readmissions of patients with heart failure are concurrent behavioral health issues that can lead to decreased medication compliance and increased risk for disease progression. The prevalence of comorbid depression is as high as 77% among patients with heart failure and may be an important factor in readmissions. Although cardiac nurses in the emergency room, intensive care unit, and the progressive care units at a community hospital were perceived by managers to be in optimal settings to assess for behavioral health issues and make referrals as appropriate, assessments were not being conducted. The purpose of the project was to determine the barriers nurses faced in completing the assessments. Four audiotaped focus groups with a total of 18 cardiac nurses were held and the data were transcribed for analysis. Using Kalcaba's comfort contexts (physical, psychospiritual, social, and environmental), the barriers identified by the nurses were categorized into a fishbone diagram and a Pareto chart. The nurses identified lack of a standardized screening tool, lack of priority given to behavioral health assessments, lack of time to conduct the assessments, and lack of a clear facility policy related to the assessments as barriers. A positive social change resulting from the project is an initiative to address the barriers and ensure that patients with heart failure are cared for in a holistic manner that addresses physical and behavioral health issues.

No description available.

This thesis investigated the experience of taking part in a psychosocial assessment following an episode of self-harm from the service user perspective. Psychosocial assessments are a key aspect of self-harm management in secondary care, designed to identify needs and risk and determine further care. This study utilised interpretative phenomenological analysis to privilege the voices of service users and produce in-depth, contextualised understandings of the experience of assessment and its impact on future help-seeking and engagement with services. Data collection consisted of semi-structured interviews with thirteen participants soon after their hospital attendance; follow-up semi-structured interviews were also completed with seven participants three months later, to explore patient-derived outcomes from assessment and hospital attendance. The lived experiences of participants were characterised by two main features: experiences of life as a struggle and of the self as “less than”. As a result of these struggles and experiences of powerlessness and devaluation, participants mostly saw self-harm and suicide as a natural progression in their narratives. Expressions of suicidal intent reflected a struggle between a desperate desire for change and hopelessness in the face of current circumstances. The key message gained from participants’ accounts of assessment was that the interaction with staff had the power to reinforce or challenge hopelessness and negative self-evaluations. In addition, the way an assessment was conducted had influence beyond the hospital: as an experience which created or reinforced expectations for future instances of help-seeking; as a deterrent or an encouragement to seek help; and as the first step along the path to change. Unfortunately, participants’ experiences of aftercare were dominated by a sense of stagnation due to the failure of services to follow through with promises of aftercare, which affected their attitudes towards future help-seeking and towards themselves. This thesis is the first study to utilise an in-depth idiographic methodology to explore and contextualise the service user experience of psychosocial assessment following self-harm within the wider circumstances of their lives. It demonstrates how patient-staff interactions within the hospital and after discharge can affect future help-seeking through reinforcing or challenging the hopelessness and self-negativity of patients.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.