Objective To identify common difficult decisions made by family carers on behalf of people with dementia, and facilitators of and barriers to such decisions, in order to produce information for family carers about overcoming barriers.Design Qualitative study to delineate decision areas through focus groups and complexity of decision making in individual interviews. Setting Community settings in London.Participants 43 family carers of people with dementia in focus groups and 46 carers who had already made such decisions in individual interviews.Results Family carers identified five core problematic areas of decision making: accessing dementia related health and social services; care homes; legal-financial matters; non-dementia related health care; and making plans for the person with dementia if the carer became too ill to care for them. They highlighted the difficulties in making proxy decisions, especially against active resistance, and their altered role of patient manager while still a family member. Families devised strategies to gain agreement in order to ensure that the person with dementia retained dignity. ConclusionsThe following strategies helped with implementation of decisions: introducing change slowly; organising legal changes for the carer as well as the patient; involving a professional to persuade the patient to accept services; and emphasising that services optimised, not impeded, independence. To access services, carers made patients' general practice appointments, accompanied them to the surgery, pointed out symptoms, gained permission to receive confidential information, asked for referral to specialist services, and used professionals' authority to gain patients' agreement. End of life decisions were particularly difficult. They were helped by knowledge of the person with dementia's previous views, clear prognostic information, and family support. Information sheets to help carers to overcome barriers to proxy decision making have been developed; their impact in practice has yet to be evaluated.

All studies were either small or used instruments with unsatisfactory psychometric properties and so our conclusions are limited by the lack of good quality evidence. The preliminary evidence suggests that most staff who remain working in homes do not have a high prevalence of psychological stress or level of symptoms.

People with obsessive-compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation and importantly what to consider when undertaking Cognitive Behaviour Therapy (CBT) for OCD in the current climate. The expert consensus is although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to e.g. increase in risk, no access to computer or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed as well as foreseeing what life may be like for those with OCD after the pandemic is over.

Aims: Department of Health guidance on dual diagnosis (DD) recommends that services measure local need, and use this to inform service planning. This study aimed to use routine clinical data to estimate the prevalence of DD and unmet treatment need in a community drug and alcohol service, and to appraise the feasibility of using routine data for such purposes. Methods: First, a screening checklist was developed to determine whether a particular service-user met DD caseness criteria. Second, the electronic care records of 227 service-users were screened for DD caseness, as well as for documentation of current and/or previous receipt of mental health treatment. Findings: Seventy-two percent screened positive for having DD. Of these, around half were not receiving current treatment for their mental health, while 37% had never received mental health treatment. Higher rates of DD were found amongst women and those in treatment for alcohol dependence. Conclusions: The findings corroborate previous research showing high prevalences of DD and unmet treatment need within drug and alcohol services in general, and amongst certain high-risk subgroups in particular. The study demonstrates that using routine data to estimate unmet treatment need is feasible within the limited resources available to frontline services.