Influences on participation in a programme addressing loneliness among people with depression and anxiety: findings from the Community Navigator Study.

BACKGROUND: Loneliness is associated with negative outcomes, including increased mortality and is common among people with mental health problems. This qualitative study, which was carried out as part of a feasibility trial, aimed to understand what enables and hinders people with severe depression and/or anxiety under the care of secondary mental health services in the United Kingdom to participate in the Community Navigator programme, and make progress with feelings of depression, anxiety and loneliness. The programme consisted of up to ten meetings with a Community Navigator and three optional group sessions. METHODS: Semi-structured interviews were carried out with participants (n = 19) shortly after programme completion. A co-produced two-stage qualitative approach, involving narrative and reflexive thematic analysis, was undertaken by members of the study's working group, which included experts by experience, clinicians and researchers. RESULTS: The narrative analysis showed that individuals have varied goals, hold mixed feelings about meeting other people and define progress differently. From the thematic analysis, six themes were identified that explained facilitators and challenges to participating in the programme: desire to connect with others; individual social confidence; finding something meaningful to do; the accessibility of resources locally; the timing of the programme; and the participant's relationship with the Community Navigator. CONCLUSIONS: We found that people with severe depression and/or anxiety supported by secondary mental health services may want to address feelings of loneliness but find it emotionally effortful to do so and a major personal challenge. This emotional effort, which manifests in individuals differently, can make it hard for participants to engage with a loneliness programme, though it was through facing personal challenges that a significant sense of achievement was felt. Factors at the individual, interpersonal and structural level, that enable or hinder an individual's participation should be identified early, so that people are able to make the best use out of the Community Navigator or other similar programmes.

The Community Navigator Study: Results from a feasibility randomised controlled trial of a programme to reduce loneliness for people with complex anxiety or depression.

BACKGROUND: Loneliness is common among people with mental health problems and predicts poorer recovery from depression and anxiety. Needs for support with loneliness and social relationships are often under-addressed in mental health services. The Community Navigator programme was designed to reduce loneliness for adults (aged 18 and above) with complex depression or anxiety who were using secondary mental health services. Acceptability and feasibility of the programme and a trial evaluation were tested in a feasibility randomised controlled trial with qualitative evaluation. METHODS: Forty participants with depression or anxiety using secondary mental health services were recruited from mental health services in two London sites and randomised to receive: the Community Navigator programme over six months in addition to routine care (n = 30); or routine care (n = 10). Measures of loneliness, depression, other clinical and social outcomes and service use were collected at baseline and six-months follow-up. Levels of engagement in the programme and rates of trial recruitment and retention were assessed. Programme delivery was assessed through session logs completed by Community Navigators. The acceptability of the programme was explored through qualitative interviews (n = 32) with intervention group participants, their family and friends, programme providers and other involved staff. RESULTS: Forty participants were recruited in four months from 65 eligible potential participants asked. No one withdrew from the trial. Follow-up interviews were completed with 35 participants (88%). Process records indicated the programme was delivered as intended: there was a median of seven meetings with their Community Navigator (of a maximum ten) per treatment group participant. Qualitative interviews indicated good acceptability of the programme to stakeholders, and potential utility in reducing loneliness and depression and anxiety. CONCLUSIONS: A definitive, multi-site randomised controlled trial is recommended to evaluate the effectiveness and cost-effectiveness of the Community Navigator programme for people with complex anxiety and depression in secondary mental health services.

Crisis resolution and home treatment in the UK: A survey of model fidelity using a novel review methodology.

Crisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. Previous UK research, based on self-report surveys, suggests that a loosely specified model has resulted in wide variations in CRTs' service delivery, organization and outcomes. A fidelity scale (developed through evidence review and stakeholder consensus) provided a means of objectively measuring adherence to a model of good practice for CRTs, via one-day fidelity reviews of UK crisis teams. Reviews included interviews with service users, carers, staff and managers, and examination of data, policies, protocols and anonymized case notes. Of the 75 teams reviewed, 49 (65%) were assessed as being moderate fidelity and the rest as low fidelity, with no team achieving high fidelity. The median score was 122 (range: 73-151; inter-quartile range: 111-132). Teams achieved higher scores on items about structure and organization, for example ease of referral, medication and safety systems, but scored poorly on items about the content of care and interventions. Despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in our sample achieved overall high fidelity. This suggests that a mandatory national policy is not in itself sufficient to achieve good quality implementation of a service model. The CRT Fidelity Scale provides a feasible and acceptable means to objectively assess model fidelity in CRTs. There is a need for development and testing of interventions to enhance model fidelity and facilitate improvements to these services.

The Community Navigator Study: a feasibility randomised controlled trial of an intervention to increase community connections and reduce loneliness for people with complex anxiety or depression.

BACKGROUND: Loneliness is associated with poor health outcomes at all ages, including shorter life expectancy and greater risk of developing depression. People with mental health problems are particularly vulnerable to loneliness and, for those with anxiety or depression, loneliness is associated with poorer outcomes. Interventions which support people to utilise existing networks and access new social contact are advocated in policy but there is little evidence regarding their effectiveness. People with mental health problems have potential to benefit from interventions to reduce loneliness, but evidence is needed regarding their feasibility, acceptability and outcomes. An intervention to reduce loneliness for people with anxiety or depression treated in secondary mental health services was developed for this study, which will test the feasibility and acceptability of delivering and evaluating it through a randomised controlled trial. METHODS: In this feasibility trial, 40 participants with anxiety or depression will be recruited through two secondary mental health services in London and randomised to an intervention (n = 30) or control group (n = 10). The control group will receive standard care and written information about local community resources. The coproduced intervention, developed in this study, includes up to ten sessions with a 'Community Navigator' over a 6-month period. Community Navigators will work with people individually to increase involvement in social activities, with the aim of reducing feelings of loneliness. Data will be collected at baseline and at 6-month follow-up - the end of the intervention period. The acceptability of the intervention and feasibility of participant recruitment and retention will be assessed. Potential primary and secondary outcomes for a future definitive trial will be completed to assess response and completeness, including measures of loneliness, depression and anxiety. Qualitative interviews with participants, staff and other stakeholders will explore experiences of Community Navigator support, the mechanisms by which it may have its effects and suggestions for improving the programme. DISCUSSION: Our trial will provide preliminary evidence of the feasibility and acceptability of Community Navigator support and of trial procedures for testing this. The results will inform a future definitive randomised controlled trial of this intervention. TRIAL REGISTRATION: ISRCTN10771821 . Registered on 3 April 2017.

A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems.

PURPOSE: There is growing evidence of significant harmful effects of loneliness. Relatively little work has focused on how best to reduce loneliness in people with mental health problems. We aim to present an overview of the current state of the art in loneliness interventions in people with mental health problems, identify relevant challenges, and highlight priorities for future research and implementation. METHODS: A scoping review of the published and grey literature was conducted, as well as discussions with relevant experts, to propose a broad classification system for types of interventions targeting loneliness. RESULTS: We categorised interventions as 'direct', targeting loneliness and related concepts in social relationships, and 'indirect' broader approaches to well-being that may impact on loneliness. We describe four broad groups of direct interventions: changing cognitions; social skills training and psychoeducation; supported socialisation or having a 'socially-focused supporter'; and 'wider community approaches'. The most promising emerging evidence appears to be in 'changing cognitions', but, as yet, no approaches have a robust evidence base. Challenges include who is best placed to offer the intervention, how to test such complex interventions, and the stigma surrounding loneliness. CONCLUSIONS: Development of clearly defined loneliness interventions, high-quality trials of effectiveness, and identifying which approaches work best for whom is required. Promising future approaches may include wider community initiatives and social prescribing. It is important to place loneliness and social relationships high on the wider public mental health and research agenda.

Development of a measure of model fidelity for mental health Crisis Resolution Teams.

BACKGROUND: Crisis Resolution Teams (CRTs) provide short-term intensive home treatment to people experiencing mental health crisis. Trial evidence suggests CRTs can be effective at reducing hospital admissions and increasing satisfaction with acute care. When scaled up to national level however, CRT implementation and outcomes have been variable. We aimed to develop and test a fidelity scale to assess adherence to a model of best practice for CRTs, based on best available evidence. METHODS: A concept mapping process was used to develop a CRT fidelity scale. Participants (n = 68) from a range of stakeholder groups prioritised and grouped statements (n = 72) about important components of the CRT model, generated from a literature review, national survey and qualitative interviews. These data were analysed using Ariadne software and the resultant cluster solution informed item selection for a CRT fidelity scale. Operational criteria and scoring anchor points were developed for each item. The CORE CRT fidelity scale was then piloted in 75 CRTs in the UK to assess the range of scores achieved and feasibility for use in a 1-day fidelity review process. Trained reviewers (n = 16) rated CRT service fidelity in a vignette exercise to test the scale's inter-rater reliability. RESULTS: There were high levels of agreement within and between stakeholder groups regarding the most important components of the CRT model. A 39-item measure of CRT model fidelity was developed. Piloting indicated that the scale was feasible for use to assess CRT model fidelity and had good face validity. The wide range of item scores and total scores across CRT services in the pilot demonstrate the measure can distinguish lower and higher fidelity services. Moderately good inter-rater reliability was found, with an estimated correlation between individual ratings of 0.65 (95% CI: 0.54 to 0.76). CONCLUSIONS: The CORE CRT Fidelity Scale has been developed through a rigorous and systematic process. Promising initial testing indicates its value in assessing adherence to a model of CRT best practice and to support service improvement monitoring and planning. Further research is required to establish its psychometric properties and international applicability.