National Institute of Health Research

HS&DR - 11/1024/08: An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services

Project title An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services
Research type Evidence Synthesis
Status Project complete
Start date February 2013
Publication date

May 2015

Link to journal publication
Cost £ 116,685.63
Chief Investigator Dr Ben Hannigan
Co-investigators Mrs Deborah Edwards (Cardiff University), Dr Nicola Evans (Cardiff University), Mrs Elizabeth Gillen (Cardiff University), Dr Mirella Longo (Swansea University), Professor Steven Pryjmachuk (The University of Manchester), Dr Gemma Trainor (Greater Manchester West Mental Health NHS Foundation Trust)
Contractor Cardiff University
Plain English summary This proposed evidence synthesis is a response to the NIHR HS&DR Programme s call for studies in the field of innovation in secondary mental health services. The call identifies four main areas in which projects will be commissioned. One of these is risk . This planned 15 month study lies in this area, and has the overall aim of bringing together what is known about risk in the context of young people moving into, through and out of inpatient mental health care. The needs of most children and young people experiencing mental health problems are safely and effectively met in the community. For those with the greatest need, highly specialised child and adolescent mental health services (CAMHS) are available at what is often referred to as tier 4 . In recent years services at tier 4 have diversified. However, hospitals continue to occupy an important place in overall systems of care, and it is hospital services which are the focus of this study. With support from the NIHR, previous studies have examined the interventions provided to young people in mental health hospitals, the advantages of inpatient care and processes supporting young people moving from CAMHS to adult mental health services. Some research has also taken place in the fields of risk identification, assessment and management in inpatient CAMHS. For example, it is known that the risks of suicide, physical deterioration due to mental illness and of serious deliberate self-harm are leading reasons for young people being admitted to hospital. However, the research in this area (along with the evidence from other sources, such as reports from local service developments and case studies) has not previously been brought together in the way that is planned here. A synthesis is needed. Very little is known about how risks are identified, assessed and managed. Whilst assessments and management of risk in the areas of harm to self or others are important for young people, other risks receiving far less attention also exist. Examples include the risks that mental ill-health and hospital admission pose to the achievement of young people s developmental milestones, or their educational attainment and social integration. This study will therefore synthesise what is known about the identification, assessment and management of constellations of risk in their broadest sense. The overall aim is to bring together research and other evidence in this area for young people (aged 11-18) using inpatient mental health services, and to establish what is known about the costs and cost effectiveness to the NHS of different approaches. Specifically the project will examine and synthesise the evidence for, and the costs to the NHS of, approaches to risk used as young people (1) make the transition into inpatient CAMHS (2) are cared for in inpatient CAMHS (3) make the transition from inpatient CAMHS to the community (4) make the transition from inpatient CAMHS to adult mental health services. The project will also make recommendations for future commissioning, service development and research. The study will follow the EPPI-Centre framework for evidence synthesis (Evidence for Policy and Practice Information and Co-ordinating Centre, 2007). This is an approach recommended for reviews where the findings are destined for practical use by policymakers, managers and other decision-makers The framework involves two stages, and supports the searching, appraisal and synthesis of the research and other evidence in ways which are transparent, rigorous and sensitive to the priorities of stakeholders. In the first, mapping , stage a search for evidence will take place using two bibliographic databases. No attempts will be made to define the meaning/s of the word risk , in order to support as comprehensive a scoping as possible. From this search a broad, descriptive, map will be produced of the different ways in which risk in inpatient CAMHS has been thought of, investigated and written about in the international literature. The project team will present this descriptive map to stakeholder representatives (including young people), and together key topic areas will be identified to take forward to the second (in-depth) phase. For each identified area research and other evidence will be sought through searches of bibliographic databases, websites and CAMHS journals. Calls for evidence will be made. Each research report passing the initial topic inclusion screening will be assessed for quality using agreed appraisal checklists. Other types of (non-research) knowledge identified will be appraised using a separate, generic, checklist. Where evidence of effectiveness is accompanied by robust costing and/or cost effectiveness analyses the quality of the economic evidence will be assessed using an agreed health economics checklist. If little or no such economic evidence is found, attempts will be made to estimate the cost of the most effective alternative approaches using data from the published/grey sources together with the most appropriate unit costs. Materials reflecting each of the agreed topic priorities will be brought together in a series of separate, parallel, narrative syntheses. In a final meta-synthesis a matrix will be developed to bring together the findings from each separate synthesis and economic analysis. Findings will be juxtaposed, so that (for example) what is known about effectiveness and costs can be set alongside what is known young people s and staff members views and experiences. The implications of what has been learned for NHS policy and practice will be set out in an accompanying narrative, and remaining gaps in knowledge identified. Future commissioning, service development and research priorities will be set out. A clear timeline has been created for this project, with identifiable milestones (e.g., for the completion of the initial mapping phase, and for project team/advisory group meetings). Team members have identified roles, and plans are in place for project management and for communicating across institutions. Work will commence in February 2013, with no ethics approval required. As a team we are well-balanced, with expertise in: project management; evidence searching, review and synthesis; qualitative and quantitative research methods; health economics; policy, management and practice in the CAMHS field; and in the production of written reports for funding bodies, journals and for use by wider stakeholde
Scientific summary An evidence synthesis guided by the EPPI-Centre framework will be conducted (Evidence for Policy and Practice Information and Co-ordinating Centre, 2007). The approach is two-stage, supporting the searching, appraisal and synthesis of the research and other evidence in ways which are transparent, rigorous and sensitive to the priorities of stakeholders, but which also reflect the complexity of the field. The overarching research question in this proposed project is: What is known about the identification, assessment and management of risk (where risk is broadly conceived) in young people (aged 11-18) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK? Specific objectives are: (1) To summarise and appraise the evidence for the identification, assessment and management of risk for young people: as they make the transition into inpatient CAMHS; as they are cared for in inpatient CAMHS; as they make the transition from inpatient CAMHS to the community; and as they make the transition from inpatient CAMHS to adult mental health services (2) To identify and describe any underlying theoretical explanations for approaches used in the identification, assessment and management of risk (3) To understand the views and experiences of risk of young people (11-18 years) with complex mental health needs using inpatient mental health services, and of those involved in the identification, assessment and management of risk in these settings (4) To synthesize the evidence for the identification, assessment and management of risk in young people (aged 11-18) with complex mental health needs entering, using and exiting inpatient services (5) To synthesize the evidence on the costs and cost effectiveness to the NHS of different approaches to identifying, assessing and managing these risks (6) To identify the future priorities for commissioning, service development and research for young people (aged 11-18) with complex mental health needs entering, using and exiting tier 4 inpatient services. Mapping exercise: An initial scoping search will be conducted using the databases Medline and PsycINFO. At this stage no attempts will be made to define the meaning/s of the word risk , in order to support as comprehensive a scoping as possible. A broad, descriptive, map will be produced of the different ways in which risk has been conceptualised, investigated and otherwise written about in the international literature, and what is currently known in the risk identification, assessment and management field in the inpatient CAMHS area. In depth review: Working with stakeholder representatives, key areas to take forward for the second phase of the review will be determined. A particular concern at this juncture will be to listen to the priorities for in-depth review identified by members of the project advisory group. Having agreed the focus for this second phase of the project, initial electronic searches and the broad descriptive mapping will be supplemented by other methods. A second, extensive, search will be undertaken using all keywords and index terms identified as relevant (including for the economic analysis component see below). Materials published in the English language since the introduction of the tiered system in CAMHS in 1995 will first be sought through searches of bibliographic databases. Sources will also be searched for relevant unpublished ( grey ) material, and calls for evidence will be made through relevant online lists and through professional networks. Titles and abstracts will be read by 2 members of the research team and considered against the topic inclusion criteria developed in consultation with the advisory group. Studies identified from reference list searches will be assessed for relevance based on publication titles. Reports of service developments, case studies and non-research materials found in the grey literature will also be read by 2 members of the project team and considered against the topic inclusion criteria. Each research report that passes the initial topic inclusion screening will be read and assessed independently for quality (using agreed appraisal checklists) by 2 team members. Studies will be assessed for methodological quality and data will be extracted using the design-appropriate checklists available from the Critical Appraisal Skills Programme (CASP) (www.casp-uk.net). Resolution of discrepancies in the independent assessments of quality will be resolved, where possible, through pair discussion. Research reports identified through searches of the grey literature will be assessed in the same way as those identified through database searching. Other types of (non-research) knowledge identified through the in-depth search will be appraised using the generic checklist developed by Wallace and Wray (2006). Economic analysis: The way the economic analysis develops will be met will largely depend on the amount and type of evidence retrieved. Where evidence of effectiveness is accompanied by robust costing and/or cost effectiveness analyses the Drummond checklist (Drummond and Jefferson, 1996) will be used to assess the quality of the economic evidence. If little or no such economic evidence is found, an attempt will be made to estimate the cost of the most effective alternative approaches using resource data from the published/grey sources together with the most appropriate unit costs. Costs will be differentiated according to objectives 1 to 4 above and for each, a further analysis will be carried out to identify key cost drivers and how they vary across the NHS and the private sector. Relevant cost and economic terms will be added to the search strategy to identify documents which include an economic component. In terms of identifying grey literature the economist team will contact key research centres such as the PSSRU at the University of Kent, and will contact key informants in the economics of mental health. Syntheses of evidence: Materials reflecting each of the agreed project team/advisory group priorities will be brought together in a series of separate, parallel, narrative syntheses. These syntheses will be prepared by members of the project team working together in sub-groups, and will be discussed and finally approved within the whole project team before being presented for further discussion and recommended refinement with the project advisory group. In a final
Outputs
  1. What do we know about the risks for young people moving into, through and out of inpatient mental health care? Findings from an evidence synthesis.

    Authors: Edwards, D. Evans, N. Gillen, E. Longo, M. Pryjmachuk, S. Trainor, G. Hannigan, B.

    Reference: Child and Adolescent Psychiatry and Mental Health 2015;10.1186/s13034-015-0087-y

Documents

Protocol (PDF File - 289.7 KB)

Commissioning Brief (PDF File - 309.0 KB)

First Look Summary (PDF File - 300.9 KB)

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