(2015) Supporting recovery in patients with psychosis using adult mental health teams (REFOCUS): a multi-site cluster randomised controlled trial. The Lancet Psychiatry, 2 (6). pp. 503-514. ISSN 2215-0374 Access from the University of Nottingham repository: http://eprints.nottingham.ac.uk/34258/1/AFD%20Lancet%20Psychiatry%20REFOCUS %20Cost-effectiveness.pdf Copyright and reuse:The Nottingham ePrints service makes this work by researchers of the University of Nottingham available open access under the following conditions. This article is made available under the University of Nottingham End User licence and may be reused according to the conditions of the licence. For more details see: http://eprints.nottingham.ac.uk/end_user_agreement.pdf A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription. Abstract BackgroundMental health policy in many countries is oriented around recovery. The evidence base for service-level pro-recovery interventions is lacking. MethodsTwo-site cluster randomised controlled trial in England (ISRCTN02507940). REFOCUS is a one-year team-level intervention targeting staff behaviour (increasing focus on patient values, preferences, strengths, goal-striving) and staff-patient relationships (coaching, partnership). 27 community-based adult mental health teams were randomly allocated to treatment-as-usual (n=13) or treatment-as-usual plus REFOCUS (n=14).Baseline (n=403) and one-year follow-up (n=297) outcomes were assessed for randomly selected patients with psychosis, representing 88% of target recruitment. Primary outcome was recovery, assessed using Questionnaire about Processes of Recovery (QPR). FindingsIntention-to-treat analysis using multiple imputation found no difference in QPR Total (control 40·0 (s.d.10·2), intervention 40·6 (s.d.10·1), adjusted difference 0·68, 95%CI: -1·7 to 3·1, p=·58), or sub-scales. Secondary outcomes which improved in the intervention group were functioning (adjusted difference 6·96, 95%CI 2·8 to 9·2, p<·001) and staff-rated unmet need (adjusted difference 0·80, 95%CI 0·2 to 1·4, p=·01). This pattern remained after covariate adjustment and completer analysis (n=275). Higherparticipating teams had higher staff-rated pro-recovery behaviour change (adjusted difference -0·4, 95%CI -0·7 to -0·2, p=·001) and patients had higher QPR Interpersonal scores (adjusted difference -1·6, 95%CI -2·7 to -0·5, p=·005) at follow-up. Interventiongroup patients incurred £1,062 (95%CI -£1,103 to £3,017) lower adjusted costs. InterpretationSupporting recovery may, from the staff perspective, improve functioning and reduce needs. Overcoming implementation barriers may increase staff pro-recovery behaviours and interpersonal aspects of patient-rated recovery.

ObjectiveTo investigate staff and trainer perspectives on the barriers and facilitators to implementing a complex intervention to help staff support the recovery of service users with a primary diagnosis of psychosis in community mental health teams.DesignProcess evaluation nested within a cluster randomised controlled trial (RCT).Participants28 interviews with mental health care staff, 3 interviews with trainers, 4 focus groups with intervention teams and 28 written trainer reports.Setting14 community-based mental health teams in two UK sites (one urban, one semi-rural) who received the intervention.ResultsThe factors influencing the implementation of the intervention can be organised under two over-arching themes: Organisational readiness for change and Training effectiveness. Organisational readiness for change comprised three sub-themes: NHS Trust readiness; Team readiness; and Practitioner readiness. Training effectiveness comprised three sub-themes: Engagement strategies; Delivery style and Modelling recovery principles.ConclusionsThree findings can inform future implementation and evaluation of complex interventions. First, the underlying intervention model predicted that three areas would be important for changing practice: staff skill development; intention to implement; and actual implementation behaviour. This study highlighted the importance of targeting the transition from practitioners' intent to implement to actual implementation behaviour, using experiential learning and target setting. Second, practitioners make inferences about organisational commitment by observing the allocation of resources, Knowledge Performance Indicators and service evaluation outcome measures. These need to be aligned with recovery values, principles and practice. Finally, we recommend the use of organisational readiness tools as an inclusion criteria for selecting both organisations and teams in cluster RCTs. We believe this would maximise the likelihood of adequate implementation and hence reduce waste in research expenditure.Trial RegistrationControlled-Trials.com ISRCTN02507940

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BackgroundThe aim of this study was to develop and evaluate a brief quantitative five-language measure of involvement and satisfaction in clinical decision-making (CDIS) – with versions for patients (CDIS-P) and staff (CDIS-S) – for use in mental health services.MethodsAn English CDIS was developed by reviewing existing measures, focus groups, semistructured interviews and piloting. Translations into Danish, German, Hungarian and Italian followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force principles of good practice for translation and cultural adaptation. Psychometricevaluation involved testing the measure in secondary mental health services in Aalborg, Debrecen, London, Naples, Ulm and Zurich.ResultsAfter appraising 14 measures, the Control Preference Scale and Satisfaction With Decision-making English-language scales were modified and evaluated in interviews (n = 9), focus groups (n = 22) and piloting (n = 16). Translations were validated through focus groups (n = 38) and piloting (n = 61). A total of 443 service users and 403 paired staff completed CDIS. The Satisfaction sub-scale had internal consistency of 0.89 (0.86-0.89 after item-level deletion) for staff and 0.90 (0.87-0.90) for service users, both continuous and categorical (utility) versions were associated with symptomatology and both staff-rated and service userrated therapeutic alliance (showing convergent validity), and not with social disability (showing divergent validity), and satisfaction predicted staff-rated (OR 2.43, 95%CI 1.54- 3.83 continuous, OR 5.77, 95%CI 1.90-17.53 utility) and service user-rated (OR 2.21, 95%CI 1.51-3.23 continuous, OR 3.13, 95%CI 1.10-8.94 utility) decision implementation two months later. The Involvement sub-scale had appropriate distribution and no floor or ceiling effects, was associated with stage of recovery, functioning and quality of life (staff only) (showing convergent validity), and not with symptomatology or social disability (showing divergent validity), and staff-rated passive involvement by the service user predicted implementation (OR 3.55, 95%CI 1.53-8.24). Relationships remained after adjusting for clustering by staff.ConclusionsCDIS demonstrates adequate internal consistency, no evidence of item redundancy, appropriate distribution, and face, content, convergent, divergent and predictive validity. It can be recommended for research and clinical use. CDIS-P and CDIS-S in all 3 five languages can be downloaded at http://www.cedar-net.eu/instruments.Trial registrationISRCTN75841675.

Smoothly curved objects elicit feelings of pleasantness and tend to be preferred over angular objects. Furthermore, individual differences (i.e., art expertise, openness to experience, holistic thinking), and the complexity of the stimuli are known to moderate the effect. We extended the study of individual differences to 2 theoretically relevant groups. Study 1 compared liking for curvature in individuals with autism and a matched neurotypical control group (for age, gender, and IQ). Because preference for curvature depends on both sensory (visuospatial) and affective input, for which individuals with autism exhibit anomalies, we hypothesized a difference in preference for curved stimuli between the 2 groups. Study 2 examined preference for curvature in a group of quasi-expert students of design. Because working architects and designers tend to regard curved interior spaces as beautiful, we hypothesized to replicate this effect within quasi-experts as well, thereby extending the effect across levels of expertise. Using an identical methodology across both studies, we administered abstract stimuli consisting of irregular polygons (angular vs. curved) and patterns of colored lines (angular vs. curved), as well as concrete stimuli consisting of images of interior spaces. Preference for curvature was confirmed with abstract stimuli in all 3 groups. For interior design, the curvature effect diminished in magnitude, and this was especially evident in individuals with autism. Interestingly, quasi-experts preferred rectilinear over curvilinear interiors. We discuss the results in relation to the impact of individual differences and expertise on preference for curvature, and their implication for design studies in ecologically valid settings.