Publications by authors named "Vanessa Lawrence"

45 Publications

The association between an early diagnosis of dementia and secondary health service use.

Age Ageing 2021 May 29. Epub 2021 May 29.

Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.

Background: dementia policy suggests diagnosing dementia early can reduce the risk of potentially harmful hospital admissions or emergency department (ED) attendances; however, there is little evidence to support this. A diagnosis of mild cognitive impairment (MCI) before dementia is a helpful proxy to explore early diagnosis. This study investigated the association between an early diagnosis of dementia and subsequent hospitalisations and ED attendances.

Method: a retrospective cohort study of electronic health care records from 15,836 patients from a large secondary care database in South London, UK. Participants were divided into two groups: those with a diagnosis of MCI before dementia, an early diagnosis, and those without. Cox regression models were used to compare the risk of hospitalisation and ED attendance after dementia diagnosis and negative binomial regression models were used to compare the average length of stay and average number of ED attendances.

Results: participants with an early diagnosis were more likely to attend ED after their diagnosis of dementia (HR = 1.09, CI = 1.00-1.18); however, there was no difference in the number of ED attendances (IRR = 1.04, CI = 0.95-1.13). There was no difference in the risk of hospitalisation (HR = 0.99, CI = 0.91-1.08) or length of stay between the groups (IRR = 0.97, CI = 0.85-1.12).

Conclusion: the findings of this study do not support the assumption that an early diagnosis reduces the risk of hospitalisation or ED attendance. The patterns of health service use in this paper could reflect help-seeking behaviour before diagnosis or levels of co-morbidity.
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http://dx.doi.org/10.1093/ageing/afab079DOI Listing
May 2021

Navigating the mental health system: Narratives of identity and recovery among people with psychosis across ethnic groups.

Soc Sci Med 2021 Jun 1;279:113981. Epub 2021 May 1.

Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK. Electronic address:

There is consistent evidence that members of the black Caribbean population in the UK are more likely to have coercive relationships with mental health services, typified by high levels of police involvement and compulsory treatment. This research has relied upon a medical epidemiological framework that has enumerated differences in service use but failed to unravel the complex interplay of individual, social, and cultural factors that inform the pathway to care. The purpose of this study was to explore the journey through mental health services from the perspective of individuals from the black Caribbean and majority white British population to help understand variation in the use of mental health services. Individual interviews were conducted with 17 black Caribbean, 15 white British, and 3 non-British white people with psychosis as part of AESOP-10, a 10 year follow up of an ethnically diverse cohort of individuals with first episode psychosis in the UK. Thematic narrative analysis identified three overarching narrative categories: 'losing self within the system' narratives gave primacy to individuals' identity as a chronic psychiatric patient with participants unable to break the cycle of service use; 'steadying self through the system' narratives combined recognition of the value of psychiatry and its limitations with the ability to access psychological therapy and protect valued social roles; 'finding strength beyond the system' narratives challenged negative dominant discourses and emphasised social, interpersonal and intrapersonal factors in recovery. We found variation in narratives across ethnic groups with 'losing self within the system' and 'finding strength beyond the system' narratives most common, though not exclusive to, black Caribbean participants. Distress appeared rooted in social structures that disadvantage black people, and psychiatry appeared to be experienced as a further form of oppression, that initially provoked resistance and fear, and over time, resignation to the identity of psychiatric patient.
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http://dx.doi.org/10.1016/j.socscimed.2021.113981DOI Listing
June 2021

Optimising psychological treatment for Anxiety DisordErs in Pregnancy (ADEPT): study protocol for a feasibility trial of time-intensive CBT versus weekly CBT.

Pilot Feasibility Stud 2021 Apr 30;7(1):101. Epub 2021 Apr 30.

Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.

Background: Moderate to severe anxiety disorders such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobia and panic disorder are common, and affect approximately 11-16% of women in pregnancy. Psychological treatments for anxiety disorders, primarily cognitive behaviour therapy (CBT), have a substantial evidence base and recently time-intensive versions have been found as effective as weekly treatments. However, this has not been trialled in women who are pregnant, where a shorter intervention may be desirable.

Methods: The ADEPT study is a feasibility randomised controlled trial with two parallel intervention groups. Time-intensive one-to-one CBT and standard weekly one-to-one CBT delivered during pregnancy will be compared. Feasibility outcomes including participation and follow-up rates will be assessed, alongside the acceptability of the interventions using qualitative methods.

Discussion: The study will provide preliminary data to inform the design of a full-scale randomised controlled trial of a time-intensive intervention for anxiety during pregnancy. This will include information on the acceptability of time-intensive interventions for pregnant women with anxiety disorders.

Trial Registration: https://doi.org/10.1186/ISRCTN81203286 prospectively registered 27/6/2019.
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http://dx.doi.org/10.1186/s40814-021-00838-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085465PMC
April 2021

Acceptance and commitment therapy for late-life treatment-resistant generalised anxiety disorder: a feasibility study.

Age Ageing 2021 Apr 13. Epub 2021 Apr 13.

Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK.

Background: Generalised anxiety disorder (GAD) is the most common anxiety disorder in older people. First-line management includes pharmacological and psychological therapies, but many do not find these effective or acceptable. Little is known about how to manage treatment-resistant generalised anxiety disorder (TR-GAD) in older people.

Objectives: To examine the acceptability, feasibility and preliminary estimates of the effectiveness of acceptance and commitment therapy (ACT) for older people with TR-GAD.

Participants: People aged ≥65 years with TR-GAD (defined as not responding to GAD treatment, tolerate it or refused treatment) recruited from primary and secondary care services and the community.

Intervention: Participants received up to 16 one-to-one sessions of ACT, developed specifically for older people with TR-GAD, in addition to usual care.

Measurements: Co-primary outcomes were feasibility (defined as recruitment of ≥32 participants and retention of ≥60% at follow-up) and acceptability (defined as participants attending ≥10 sessions and scoring ≥21/30 on the satisfaction with therapy subscale). Secondary outcomes included measures of anxiety, worry, depression and psychological flexibility (assessed at 0 and 20 weeks).

Results: Thirty-seven participants were recruited, 30 (81%) were retained and 26 (70%) attended ≥10 sessions. A total of 18/30 (60%) participants scored ≥21/30 on the satisfaction with therapy subscale. There was preliminary evidence suggesting that ACT may improve anxiety, depression and psychological flexibility.

Conclusions: There was evidence of good feasibility and acceptability, although satisfaction with therapy scores suggested that further refinement of the intervention may be necessary. Results indicate that a larger-scale randomised controlled trial of ACT for TR-GAD is feasible and warranted.
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http://dx.doi.org/10.1093/ageing/afab059DOI Listing
April 2021

A peer interview qualitative study exploring support for carers of people with comorbid autism and eating disorders.

J Eat Disord 2021 Mar 31;9(1):42. Epub 2021 Mar 31.

King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.

Background: Carers of people with eating disorders (EDs) are known to experience a lack of support, high levels of unmet needs and resulting distress. Specific support and interventions for carers may benefit both the carer, and their loved one with an ED. Individuals with co-occurring autism and EDs may present with additional needs and difficulties relating to their Autism Spectrum Condition (ASC) that impact their carers. However, there is a lack of research exploring whether carers of people with ASC and EDs have specific support needs, and what kinds of support may be most beneficial for this population.

Methods: This study used a qualitative interview design, utilising peer interviews. Eleven carers participated in interviews about their experiences as a carer, and their views on existing support systems and potential improvements. As the study took place during the initial UK coronavirus lockdown, the impact of the lockdown also emerged as a topic during the interviews. Interviews were transcribed and analysed using thematic analysis.

Results: Five themes were identified: challenges associated with co-occurring Autism and EDs, a lack of existing support for carers from healthcare services, the personal impact of caring for someone with both ASC and EDs, ideas for how carers can be best supported, and the impact of the coronavirus on carers.

Conclusions: Carers of loved ones with both ASC and EDs described the experience as having a significant personal impact on their lives, but also experienced a lack of support from healthcare services. There was a perception that caring for someone with both an ASC and EDs presents additional challenges compared to caring for someone with an ED only, and that this population therefore requires specialised support. Recommendations for possible support options, and for further research, are outlined.
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http://dx.doi.org/10.1186/s40337-021-00397-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010292PMC
March 2021

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders.

J Eat Disord 2021 Jan 6;9(1). Epub 2021 Jan 6.

Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed.

Objective: This study aimed to assess emerging adults' experiences of receiving treatment through FREED.

Method: This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically.

Results: Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist.

Conclusion: This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.
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http://dx.doi.org/10.1186/s40337-020-00354-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789709PMC
January 2021

The Association Between a Previous Diagnosis of Mild Cognitive Impairment as a Proxy for an Early Diagnosis of Dementia and Mortality: A Study of Secondary Care Electronic Health Records.

J Alzheimers Dis 2021 ;79(1):267-274

Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Dementia policy states that the early diagnosis of dementia can keep people living well for longer; however, there is little robust evidence to support this. Mild cognitive impairment (MCI) is considered a prodrome to dementia and can aid with the earlier diagnosis of dementia.

Objective: The objective of this study was to use a previous diagnosis of MCI, before dementia, as a proxy for early diagnosis to investigate the relationship between an early diagnosis and mortality.

Methods: A retrospective cohort study of electronic health care records from South London and Maudsley NHS. Patients aged 50+, diagnosed with dementia between January 2008 and November 2018, were divided into two groups: those with a previous diagnosis of MCI (early diagnosis) and those without. Cox regression models used to compare the risk of mortality between groups.

Results: Of 18,557 participants, 5.6%(n = 1,030) had an early diagnosis; they had fewer cognitive, psychiatric, and functional problems at dementia diagnosis. The early diagnosis group had a reduced hazard of mortality (HR = 0.86, CI = 0.77-0.97). However, the magnitude of this effect depended on the scale used to adjust for cognitive difficulties.

Conclusion: A previous diagnosis of MCI is a helpful proxy for early diagnosis. There is some evidence that an early diagnosis is associated with a reduced risk of mortality; however, it is not clear how Mini-Mental State Exam scores affect this relationship. While these findings are promising, we cannot be conclusive on the relationship between an early diagnosis and mortality.
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http://dx.doi.org/10.3233/JAD-200978DOI Listing
January 2021

"Now It's Just Old Habits and Misery"-Understanding the Impact of the Covid-19 Pandemic on People With Current or Life-Time Eating Disorders: A Qualitative Study.

Front Psychiatry 2020 27;11:589225. Epub 2020 Oct 27.

Section of Eating Disorders, Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.

Many aspects of the Covid-19 pandemic may make living with or recovery from an eating disorder (ED) particularly challenging. Understanding the processes which underlie the psychological and behavioral responses of people with EDs during this time are key to ensure tailored support in these unprecedented circumstances. People with lifetime EDs ( = 32) were recruited through social media from May to June 2020 during a period of strict infection control measures in the United Kingdom (i.e., "lockdown," "social distancing"). They completed open-ended questions in an online anonymous questionnaire that invited them to reflect on how various aspects of their lives have been affected by the Covid-19 pandemic, including ED symptoms and coping strategies. Responses were analyzed using thematic analysis. Most respondents reported that their ED worsened or resurfaced. Isolation, low mood, anxiety, lack of structure, disruption to routines, and media/social media messages around weight and exercise seemed to contribute to this. There was a clear sense that individuals struggled with which aspects of psychological distress to prioritize, i.e., mood vs. ED cognitions and behaviors, particularly as attempts to cope with one often exacerbated the other. Nonetheless, some participants reported "silver linings" of the pandemic. In this self-selected sample, deterioration or recurrence of ED symptoms were the norm. This has implications for the provision of treatment and care for people with EDs both in the immediate short-term and in potential future waves of the pandemic, with a significant surge of new and re-referrals expected.
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http://dx.doi.org/10.3389/fpsyt.2020.589225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653176PMC
October 2020

"I'm not a teenager, I'm 22. Why can't I snap out of it?": a qualitative exploration of seeking help for a first-episode eating disorder during emerging adulthood.

J Eat Disord 2020 3;8:46. Epub 2020 Sep 3.

King's College London, Institute of Psychiatry, Psychology and Neuroscience, Section of Eating Disorders, London, UK.

Background: Eating disorders (EDs) typically have their onset during adolescence or the transition to adulthood. Emerging adulthood (~ 18-25 years) is a developmental phase which conceptually overlaps with adolescence but also has unique characteristics (e.g. increased independence). Emerging adults tend to come to ED services later in illness than adolescents, and emerging adulthood's unique characteristics may contribute to such delays

Objective: This study aimed to explore attitudes towards ED symptoms, and their implications for help-seeking, amongst emerging adults receiving ED treatment through FREED, an early intervention care pathway.

Method: Participants were 14 emerging adults (mean age 20.9 years; SD = 2.0), all currently receiving specialist treatment for a first-episode, recent-onset (< 3 years) ED. Semi-structured interviews relating to experiences of help-seeking were conducted, and data were analysed thematically.

Results: Symptom egosyntonicity, gradual reappraisal and feelings of exclusion from ED discourse were key attitudinal phases prior to help-seeking, each of which had distinct implications for help-seeking.

Conclusions: Emerging adults with first-episode EDs show a distinct set of help-seeking-related challenges and opportunities (e.g. help-seeking for others; help-seeking at transitions; self-sufficiency). This research might be used to inform the development and evaluation of interventions which aim to facilitate help-seeking amongst emerging adults with first-episode recent-onset EDs.
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http://dx.doi.org/10.1186/s40337-020-00320-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469268PMC
September 2020

Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis.

J Med Internet Res 2020 09 2;22(9):e20581. Epub 2020 Sep 2.

Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.

Background: Digital interventions targeting common mental disorders (CMDs) or symptoms of CMDs are growing rapidly and gaining popularity, probably in response to the increased prevalence of CMDs and better awareness of early help-seeking and self-care. However, no previous systematic reviews that focus on these novel interventions were found.

Objective: This systematic review aims to scope entirely web-based interventions that provided screening and signposting for treatment, including self-management strategies, for people with CMDs or subthreshold symptoms. In addition, a meta-analysis was conducted to evaluate the effectiveness of these interventions for mental well-being and mental health outcomes.

Methods: Ten electronic databases including MEDLINE, PsycINFO, and EMBASE were searched from January 1, 1999, to early April 2020. We included randomized controlled trials (RCTs) that evaluated a digital intervention (1) targeting adults with symptoms of CMDs, (2) providing both screening and signposting to other resources including self-care, and (3) delivered entirely through the internet. Intervention characteristics including target population, platform used, key design features, and outcome measure results were extracted and compared. Trial outcome results were included in a meta-analysis on the effectiveness of users' well-being and mental health outcomes. We also rated the meta-analysis results with the Grading of Recommendations, Assessment, Development, and Evaluations approach to establish the quality of the evidence.

Results: The electronic searches yielded 21 papers describing 16 discrete digital interventions. These interventions were investigated in 19 unique trials including 1 (5%) health economic study. Most studies were conducted in Australia and North America. The targeted populations varied from the general population to allied health professionals. All interventions offered algorithm-driven screening with measures to assess symptom levels and to assign treatment options including automatic web-based psychoeducation, self-care strategies, and signposting to existing services. A meta-analysis of usable trial data showed that digital interventions improved well-being (3 randomized controlled trials [RCTs]; n=1307; standardized mean difference [SMD] 0.40; 95% CI 0.29 to 0.51; I=28%; fixed effect), symptoms of mental illness (6 RCTs; n=992; SMD -0.29; 95% CI -0.49 to -0.09; I=51%; random effects), and work and social functioning (3 RCTs; n=795; SMD -0.16; 95% CI -0.30 to -0.02; I=0%; fixed effect) compared with waitlist or attention control. However, some follow-up data failed to show any sustained effects beyond the post intervention time point. Data on mechanisms of change and cost-effectiveness were also lacking, precluding further analysis.

Conclusions: Digital mental health interventions to assess and signpost people experiencing symptoms of CMDs appear to be acceptable to a sufficient number of people and appear to have enough evidence for effectiveness to warrant further study. We recommend that future studies incorporate economic analysis and process evaluation to assess the mechanisms of action and cost-effectiveness to aid scaling of the implementation.
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http://dx.doi.org/10.2196/20581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495259PMC
September 2020

Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression.

Am J Geriatr Psychiatry 2021 02 4;29(2):192-203. Epub 2020 Jun 4.

Department of Health Services and Population Research, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom. Electronic address:

Objective: To adapt and optimize problem adaptation therapy for depression in dementia by grounding it in the lives of people with dementia, caregivers and clinicians.

Methods: A person-centered qualitative approach was taken to elicit the unique cognitive, psychological and social needs of people with dementia relevant to the adaptation of the intervention. A two-stage design was used: the first involved interviews and focus groups to identify priorities and concerns surrounding depression in dementia, the second trialling of the adapted intervention.

Participants: Ten people with dementia and nine caregivers participated in individual interviews, 35 healthcare practitioners and clinical academics with experience of working with dementia participated in focus groups.

Results: The findings highlight the importance of addressing key themes that typified the experience of depression among people with dementia including: a profound sense of isolation and role loss, the feeling of being both a burden and poorly understood, polarized thinking, interpersonal tensions, diverging views among carers and people with dementia about their capabilities, and changeability in cognitive ability and mood. These themes were used to inform adaptation of the intervention manual, ensuring that its content and delivery addressed the concerns of both people with depression and dementia and those who support them.

Conclusion: Implications for PATH included a focus on facilitating open communication, supporting the continuation of valued roles, and improving confidence.
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http://dx.doi.org/10.1016/j.jagp.2020.05.025DOI Listing
February 2021

Stigmatisation of those with mental health conditions in the acute general hospital setting. A qualitative framework synthesis.

Soc Sci Med 2020 06 28;255:112974. Epub 2020 Apr 28.

Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK. Electronic address:

Rationale: Patients with long-term mental health conditions often have complex physical, mental, and social needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the acute healthcare setting, to target areas for future intervention.

Objective: A synthesis of qualitative literature was undertaken in order to understand how patients with long-term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system.

Method: A theory-driven framework approach was implemented. Existing stigma theory was used to outline a framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system.

Results: A systematic literature search of qualitative studies identified a sample of 51 studies that would inform the framework. Using data in these studies, a final theoretical 'best fit' framework was developed. In this framework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance, rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours - valuing, adjustment, responding, legitimising, and positive action - which contrast with the stigmatisation patterns.

Conclusions: The study offers a framework for identifying stigmatisation and positive treatment of those with mental health conditions in an acute health setting. This framework is of potential value in targeting areas for improved quality of care and may have utility beyond this setting and stigmatised group.
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http://dx.doi.org/10.1016/j.socscimed.2020.112974DOI Listing
June 2020

An interpretative phenomenological analysis of the experience of receiving a diagnosis of bi-polar disorder.

J Ment Health 2020 Jun 24;29(3):358-363. Epub 2020 Apr 24.

Psychology Department, Institute of Psychiatry, King's College London, London, UK.

Research has shown that receiving a psychiatric diagnosis can have both positive and negative consequences for people. The way in which diagnoses are imparted is an under-researched area and may play an important role in reducing stigma and aiding recovery. The aim of the present study was to get an in-depth understanding of service users' experience of receiving a diagnosis of bipolar disorder. Nine service users recently diagnosed with bipolar disorder were interviewed using a semi-structured interview schedule designed to elicit information regarding the positive and negative aspects of receiving their diagnosis. All transcripts were analysed using Interpretative Phenomenological Analysis (IPA). The findings can be described in terms of three master themes: 1. "Perceived fit between diagnosis and lived experience", 2. "Evaluating the utility of carrying the diagnostic label" and 3. "The role of diagnosis in searching for solutions to one's difficulties". This study draws attention to the importance of evaluating the fit between diagnosis and personal experiences and to the relevance of perceived stigma. The findings also highlight the significance of the client-clinician relationship in establishing fit and instilling hope, which has implications for the acceptance of the diagnosis and engagement with services.
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http://dx.doi.org/10.1080/09638237.2020.1755020DOI Listing
June 2020

Outcomes tested in non-pharmacological interventions in mild cognitive impairment and mild dementia: a scoping review.

BMJ Open 2020 04 20;10(4):e035980. Epub 2020 Apr 20.

Health Service and Population Research, King's College London, London, UK.

Objectives: Non-pharmacological treatments are an important aspect of dementia care. A wide range of interventions have been trialled for mild dementia and mild cognitive impairment (MCI). However, the variety of outcome measures used in these trials makes it difficult to make meaningful comparisons. The objective of this study is to map trends in which outcome measures are used in trials of non-pharmacological treatments in MCI and mild dementia.

Design: Scoping review.

Data Sources: EMBASE, PsychINFO, Medline and the Cochrane Register of Controlled Trials were searched from inception until February 2018. An additional search was conducted in April 2019 ELIGIBILITY: We included randomised controlled trials (RCTs) testing non-pharmacological interventions for people diagnosed with MCI or mild dementia. Studies were restricted to full RCTs; observational, feasibility and pilot studies were not included.

Charting Methods: All outcome measures used by included studies were extracted and grouped thematically. Trends in the types of outcome measures used were explored by type of intervention, country and year of publication.

Results: 91 studies were included in this review. We extracted 358 individual outcome measures, of which 78 (22%) were used more than once. Cognitive measures were the most frequently used, with the Mini-Mental State Examination being the most popular.

Conclusions: Our findings highlight an inconsistency in the use of outcome measures. Cognition has been prioritised over other domains, despite previous research highlighting the importance of quality of life and caregiver measures. To ensure a robust evidence base, more research is needed to highlight which outcome measures should be used over others.

Prospero Registration Number: CRD42018102649.
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http://dx.doi.org/10.1136/bmjopen-2019-035980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204934PMC
April 2020

Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management.

J Neurol Neurosurg Psychiatry 2020 05 25;91(5):512-519. Epub 2020 Mar 25.

Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, London, UK.

Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson's disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson's disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.
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http://dx.doi.org/10.1136/jnnp-2019-322702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231441PMC
May 2020

Needs and preferences for psychological interventions of people with motor neuron disease.

Amyotroph Lateral Scler Frontotemporal Degener 2019 11 12;20(7-8):521-531. Epub 2019 Jul 12.

Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK.

There is a lack of knowledge about what factors may impede or facilitate engagement in psychological interventions in people with motor neuron disease (pwMND) and how such interventions can be adapted to best meet the needs of this population. To explore the needs and preferences of pwMND with respect to psychological interventions, and how best to adapt such interventions for pwMND. A series of semi-structured interviews ( = 22) and workshops ( = 3) were conducted with pwMND ( = 15), informal caregivers of pwMND ( = 10), and MND healthcare professionals ( = 12). These explored preferences and concerns that would need to be considered when delivering a psychological intervention for pwMND. Three areas were explored: (i) perceived factors that may hinder or facilitate pwMND engaging with psychological interventions; (ii) ways in which such interventions could be adapted to meet the individual needs of pwMND; and (iii) views regarding the main psychological issues that would need to be addressed. Workshops and interviews were audio recorded and transcribed and thematic analysis was used to inductively derive themes. Data could be classified within four overarching themes: unfamiliar territory; a series of losses; variability and difficulty meeting individual needs; and informal support. : Flexibility, tailoring interventions to the individual needs of pwMND, and encouraging autonomy are key attributes for psychological interventions with pwMND. Psychological interventions such as Acceptance and Commitment Therapy (ACT) could be acceptable for pwMND if adapted to their specific needs.
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http://dx.doi.org/10.1080/21678421.2019.1621344DOI Listing
November 2019

Optimising the acceptability and feasibility of acceptance and commitment therapy for treatment-resistant generalised anxiety disorder in older adults.

Age Ageing 2019 09;48(5):741-750

Division of Psychiatry, University College London, London, UK.

Background: generalised anxiety disorder (GAD) is common in later life with a prevalence of 3-12%. Many only partially respond to cognitive behavioural therapy or pharmacotherapy and can be classified as treatment resistant. These patients experience poor quality of life, and are at increased risk of comorbid depression, falls and loneliness. Acceptance and commitment therapy (ACT) is an emerging therapy, which may be particularly suited to this population, but has not been tailored to their needs.

Objectives: to optimise the acceptability and feasibility of ACT for older adults with treatment-resistant GAD.

Design: a person-based approach to ground the adapted ACT intervention in the perspectives and lives of those who will use it.

Methods: first, we conducted qualitative interviews with 15 older adults with GAD and 36 healthcare professionals to develop guiding principles to inform the intervention. Second, we consulted service users and clinical experts and interviewed the same 15 older adults using 'think aloud' techniques to enhance its acceptability and feasibility.

Results: in Stage 1, older adults' concerns and needs were categorised in four themes: 'Expert in one's own condition', 'Deep seated coping strategies', 'Expert in therapy' and 'Support with implementation'. In Stage 2, implications for therapy were identified that included an early focus on values and ACT as a collaborative partnership, examining beliefs around 'self as worrier' and the role of avoidance, validating and accommodating individuals' knowledge and experience and compensating for age-related cognitive changes.

Discussion: Our systematic approach combined rigour and transparency to develop a therapeutic intervention tailored to the specific needs of older adults with treatment-resistant GAD.
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http://dx.doi.org/10.1093/ageing/afz082DOI Listing
September 2019

Independence and the pernicious threat of multimorbidity.

Authors:
Vanessa Lawrence

Age Ageing 2019 07;48(4):472-473

King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Services & Population Research Department, De Crespigny Park, London, UK.

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http://dx.doi.org/10.1093/ageing/afz024DOI Listing
July 2019

Depression in carers of people with dementia from a minority ethnic background: Systematic review and meta-analysis of randomised controlled trials of psychosocial interventions.

Int J Geriatr Psychiatry 2019 06 15;34(6):790-806. Epub 2019 Apr 15.

Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Objectives: Systematic review and meta-analysis to determine the effectiveness of interventions in reducing depressive symptoms in ethnic minority carers of people with dementia.

Methods: We systematically searched EMBASE, CINAHL, MEDLINE, PsycINFO, PsycARTICLES, Applied Social Sciences Index and Abstracts (ASSIA), The Cochrane Central Register of Controlled Trials (CENTRAL), and Sociological Abstracts and Social Policy and Practices databases from 1990 to 2015, supplemented by a grey literature search, hand searches of bibliographies, and contacting authors. Study quality was assessed independently by two researchers using The Effective Public Health Practice Project Quality Assessment Tool, with an inter-rater reliability of Cohen's kappa of 0.72 (95% CI, 0.42-1.01). Narrative synthesis and meta-analysis were used to assess intervention effectiveness. Meta-regression was used to assess whether factors such as intervention type, peer support, and ethnicity accounted for hetereogeneity.

Results: Thirteen studies were eligible for inclusion, with 1076 participants in control groups and 980 participants in intervention groups; 12 studies provided estimates for meta-analysis. All studies were from the United States. Interventions were associated with an overall mean reduction in depression in caregivers (SMD -0.17 (95% CI, -0.29 to -0.05; P = 0.005). Meta-regression did not indicate any potential sources of heterogeneity, although narrative synthesis suggested that interventions developed with the target ethnic minority group's preferred mode of engagement in mind alongside cultural adaptations may have enhanced effectiveness.

Conclusions: Psychosocial interventions for depression in ethnic minority carers of people with dementia are effective and could be enhanced through cultural adaptations. High-quality studies targeting minority ethnic groups outside of the United States are needed.
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http://dx.doi.org/10.1002/gps.5070DOI Listing
June 2019

What influences the sustainability of an effective psychosocial intervention for people with dementia living in care homes? A 9 to 12-month follow-up of the perceptions of staff in care homes involved in the WHELD randomised controlled trail.

Int J Geriatr Psychiatry 2019 05 6;34(5):674-682. Epub 2019 Mar 6.

Center for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway.

Objectives: The study aims to understand the factors that care home staff felt enabled or hindered them in continuing to use the well-being and health for people with dementia (WHELD) psychosocial approach in their care home and investigate whether there was sustained activity 9 to 12 months after the study ended.

Methods: This qualitative study is part of a wider clinical trial, which demonstrated effectiveness of a psychosocial intervention on quality of life outcomes and neuropsychiatric symptoms for residents. Forty-seven care home staff within nine care homes in the United Kingdom participated in focus groups, between 9 and 12 months after the intervention had finished. Inductive thematic analysis was used to identify themes and interpret the data.

Results: The findings highlighted that staff continued to use a range of activities and processes acquired through the research intervention, after the study had ended. Three overarching themes were identified as influential: "recognising the value" of the approach for residents and staff, "being well practiced" with sufficient support and opportunity to consolidate skills prior to the withdrawal of the researchers, and "taking ownership of the approach" to incorporate it as usual care.

Conclusions: The WHELD approach can be sustained where the value of the approach is recognised, and sufficient support is provided during initial implementation for staff to build skills and confidence for it to become routine care. Further follow-up is required to understand longer term use and the impact for residents.
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http://dx.doi.org/10.1002/gps.5066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594193PMC
May 2019

Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK.

BMJ Open 2019 01 24;9(1):e024803. Epub 2019 Jan 24.

Centre for Implementation Science, Health Service & Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.

Objective: Lack of access to mental health services during the perinatal period is a significant public health concern in the UK. Barriers to accessing services may occur at multiple points in the care pathway. However, no previous reviews have investigated multilevel system barriers or how they might interact to prevent women from accessing services. This review examines women, their family members' and healthcare providers' perspectives of barriers to accessing mental health services for women with perinatal mental illness in the UK.

Design: A systematic review and meta-synthesis of qualitative studies.

Data Sources: Qualitative studies, published between January 2007 and September 2018, were identified in MEDLINE, PsycINFO, EMBASE and CINAHL electronic databases, handsearching of reference lists and citation tracking of included studies. Papers eligible for inclusion were conducted in the UK, used qualitative methods and were focused on women, family or healthcare providers working with/or at risk of perinatal mental health conditions. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies.

Results: Of 9882 papers identified, 35 studies met the inclusion criteria. Reporting of emergent themes was informed by an existing multilevel conceptual model. Barriers to accessing mental health services for women with perinatal mental illness were identified at four levels: Individual (eg, stigma, poor awareness), organisational (eg, resource inadequacies, service fragmentation), sociocultural (eg, language/cultural barriers) and structural (eg, unclear policy) levels.

Conclusions: Complex, interlinking, multilevel barriers to accessing mental health services for women with perinatal mental illness exist. To improve access to mental healthcare for women with perinatal mental illness multilevel strategies are recommended which address individual, organisational, sociocultural and structural-level barriers at different stages of the care pathway.

Prospero Registration Number: CRD42017060389.
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http://dx.doi.org/10.1136/bmjopen-2018-024803DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347898PMC
January 2019

"We should see her like part of the team": an investigation into care home staff's experiences of being part of an RCT of a complex psychosocial intervention.

Aging Ment Health 2020 01 20;24(1):178-185. Epub 2018 Dec 20.

Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

To contribute to improvements in the design and delivery of intervention research in care homes by adopting a collaborative approach that listens to the experiences of care home staff who had participated in a clinical trial aimed at optimising and evaluating a psychosocial intervention package for people with dementia. Qualitative study involving focus group discussions (FGDs) involving 41 staff across 6 care homes with the UK. Inductive thematic analysis was used to identify themes and interpret the data. Three overarching themes emerged as influential: Recognising preparedness; working together and learning more than expected. The findings highlighted the need to be attentive in addressing staff expectations, the value of sustained relationships and recognition of good practice. The FGDs also identified areas of unanticipated learning that staff and managers adopted. The FGDs showed the importance of considering the overall experience of care home staff who are involved in research and the importance of valuing the skills and experience they hold through positive affirmation. There are often unanticipated consequences of research involvement both on staff practice and on relationships which if promoted could help sustain effective ways of working together.
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http://dx.doi.org/10.1080/13607863.2018.1525603DOI Listing
January 2020

Visual hallucinations in dementia and Parkinson's disease: A qualitative exploration of patient and caregiver experiences.

Int J Geriatr Psychiatry 2018 10 28;33(10):1327-1334. Epub 2018 Jun 28.

Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Objectives: Visual hallucinations (VHs) can occur in several clinical conditions, of which the dementias, broadly defined, and Parkinson's disease rank among the most common. There is limited research on the lived experience of hallucinations among affected individuals and therefore a lack of evidence-based management strategies. This study used qualitative methods to explore the VH experience of individuals with dementia or Parkinson's disease and their informal caregivers.

Methods: In-depth interviews were conducted with 10 individuals with VHs and dementia and 11 informal caregivers, and 11 individuals with VHs and Parkinson's disease and 9 informal caregivers. Interviews were analysed using an inductive thematic approach.

Results: Three themes emerged from the data: "Insight and distress," "Caregiver approach: challenging v reassurance," and "Normality and stigma." Insight appeared to affect whether hallucinations were perceived as threatening and whether acceptance occurred over time. Emotional reactions and management strategies varied as insight changed with disease progression. Concerns around stigmatisation negatively influenced help-seeking and acceptance of the hallucinations.

Conclusions: Degree of insight and cognitive ability appear fundamental to the lived experience of hallucinations. Irrespective of the clinical context, support in early stages should focus on raising awareness of VH, symptom disclosure, stigma reduction, and contact with others affected. In later stages, the focus shifts to informal caregiver needs and a flexible approach to reassuring those affected.
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http://dx.doi.org/10.1002/gps.4929DOI Listing
October 2018

Current practice and challenges in night-time care for people with dementia living in care homes: a qualitative study.

Int J Geriatr Psychiatry 2018 Jan 26;33(1):e140-e149. Epub 2017 May 26.

Wolfson Centre for Age-Related Diseases, King's College London, London, UK.

Objective: To explore the current practices and challenges in night-time care for people with dementia living in care homes in the UK.

Methods: Focus group discussions (FGD) were held with care staff and family carers from five care homes in South London. To supplement the FGD data, an online survey was circulated to family carers (n = 16), and informal interviews were conducted with night-time care staff and nurses (n = 19). The questions for the online survey were designed to specifically explore the themes that emerged from the FGD.

Results: Thematic analysis revealed eight key themes in the management of sleep disturbance in people with dementia living in care homes: current night-time care practices, dissonance in perceived causes of sleep disturbances, inconsistencies in treatment options, insufficient staffing levels, working relationships between shifts, nurse burden and responsibility, communication as a critical challenge, connecting with residents and one overarching theme of balance.

Conclusions: The findings of this study highlight the need for an evidence-based sleep disturbance management programme designed for use in care homes and informed by stakeholders. The key themes identified represent the major barriers to good quality care and areas which future programmes will need to address to improve the quality of night-time care in care homes. There are clearly opportunities for future examination of non-pharmacological night-time care management programmes for use in the population. Copyright © 2017 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/gps.4737DOI Listing
January 2018

Feasibility of a staff training and support programme to improve pain assessment and management in people with dementia living in care homes.

Int J Geriatr Psychiatry 2018 Jan 5;33(1):221-231. Epub 2017 May 5.

Wolfson Centre for Age-Related Diseases, King's College London, London, UK.

Objectives: The objective of this study was to establish the feasibility and initial effectiveness of training and support intervention for care staff to improve pain management in people with dementia living in care homes (PAIN-Dem).

Methods: PAIN-Dem training was delivered to care staff from three care homes in South London, followed by intervention support and resources to encourage improved pain management by staff over 4 weeks. Feasibility was assessed through fidelity to intervention materials and qualitative approaches. Focus group discussions with staff explored the use of the PAIN-Dem intervention, and interviews were held with six residents and family carers. Pain was assessed in all residents at baseline, 3 and 4 weeks, and goal attainment scaling was assessed at 4 weeks.

Results: Delivery of training was a key driver for success and feasibility of the PAIN-Dem intervention. Improvements in pain management behaviour and staff confidence were seen in homes where training was delivered in a care home setting across the care team with good manager buy-in. Family involvement in pain management was highlighted as an area for improvement. Goal attainment in residents was significantly improved across the cohort, although no significant change in pain was seen.

Conclusions: This study shows good initial feasibility of the PAIN-Dem intervention and provides valuable insight into training and support paradigms that deliver successful learning and behaviour change. There is a need for a larger trial of PAIN-Dem to establish its impact on resident pain and quantifiable staff behaviour measures. Copyright © 2017 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/gps.4727DOI Listing
January 2018

Participant Experiences of Attending a Community CBT Workshop for Insomnia: A Qualitative Six-Year Follow-Up.

Behav Sleep Med 2019 Mar-Apr;17(2):156-173. Epub 2017 Apr 7.

Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England.

Our aim was to qualitatively explore the experiences of people who attended a one-day sleep workshop six years previously. Of the 95 people who originally attended the workshop and a three-month follow-up, 14 individuals (mean age = 63.6 years) participated. Semi-structured interviews were used to explore: participants' experiences of insomnia since the workshop, memories of the techniques and information provided and the perceived impact of the workshop on their lives. Qualitative data were analyzed using the principles of Framework Analysis. Interviews produced rich accounts of attributions of changes in sleep, the application of taught strategies and general experiences of the workshop. This research highlights which aspects of a large-scale intervention may be most helpful for individuals experiencing sleep difficulties and what factors may contribute to changes in sleep over time.
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http://dx.doi.org/10.1080/15402002.2017.1301942DOI Listing
July 2020

The landscape of pain management in people with dementia living in care homes: a mixed methods study.

Int J Geriatr Psychiatry 2016 12 21;31(12):1354-1370. Epub 2016 Feb 21.

Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Objectives: The aim of this study is to explore the current landscape of pain management in people with dementia living in care home settings. Pain is extremely common in this patient group, yet there is very limited guidance for healthcare professionals.

Methods: Triangulation of stakeholder consultation and quality review of pain management guidance were performed. A review of existing pain management guidance was conducted using published quality criteria adapted for the field. Three focus group discussions were held with care home staff and two focus group discussions and an online survey with family carers. Data were subjected to thematic analysis to identify themes and sub-themes. Outcomes were reviewed by an expert panel, which gave recommendations.

Results: Fifteen existing guidelines were identified, of which three were designed for use in dementia and none were tailored for care home settings. Thematic analysis revealed six major themes in current pain management in dementia: importance of person-centredness, current lack of pain awareness in staff, communication as a core element, disparities in staff responsibility and confidence, the need for consistency of care and current lack of staff training. In addition to the needs for practice, the expert panel identified promising pharmacological treatment candidates, which warrant clinical evaluation.

Conclusions: The findings of this study clearly articulate a need for an evidence-based pain management programme for care homes, which is informed by stakeholder input and based within a conceptual framework for this setting. There are novel opportunities for clinical trials of alternative analgesics for use in this patient group. Copyright © 2016 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/gps.4445DOI Listing
December 2016

Exploration of Friendship Experiences, before and after Illness Onset in Females with Anorexia Nervosa: A Qualitative Study.

PLoS One 2016;11(9):e0163528. Epub 2016 Sep 27.

Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

Background: Difficulties with social relationships have been implicated in both the development and maintenance of Anorexia Nervosa (AN) but the friendship experiences of individuals with AN have not been explored in depth.

Method: Ten adults with AN took part in a semi-structured interview about their friendship experiences both before and since the onset of their illness.

Results: Five principle themes were identified through thematic analysis: Social Concern; Impact of AN; Social Connectedness; Inflexibility and Preferred Social Activity. Difficulties with friendship were present prior to the onset of AN in all cases, with participants experiencing anxiety in relation to various aspects of their friendships. Participants described mixed experiences of how their AN has affected their friendships but most participants described having less contact with their friends since becoming unwell.

Conclusion: This research highlights the role that social difficulties may play in the development of AN, whilst also emphasising the importance of addressing problems with friendship in the course of inpatient treatment.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0163528PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038934PMC
September 2016

Helping staff to implement psychosocial interventions in care homes: augmenting existing practices and meeting needs for support.

Int J Geriatr Psychiatry 2016 Mar 20;31(3):284-93. Epub 2015 Jul 20.

Institute of Psychiatry, Psychology & Neurology, King's College London, London, UK.

Objective: To contribute to an optimised training programme for care staff that supports the implementation of evidence-based psychosocial interventions in long-term care.

Methods: Qualitative study that involved focus group discussions with 119 care home staff within 16 care homes in the UK. Part of wider clinical trial aimed at developing and evaluating an effective and practical psychosocial intervention and implementation approach for people with dementia in long-term care. Inductive thematic analysis was used to identify themes and interpret the data.

Results: The findings highlighted that successful training and support interventions must acknowledge and respond to 'whole home' issues. Three overarching themes emerged as influential: the importance of contextual factors such as staff morale, interpersonal relationships within the home, and experience and perceived value of the proposed intervention.

Conclusions: Priority must be given to obtain the commitment of all staff, management and relatives to the training programme and ensure that expectations regarding interaction with residents, participation in activities and the reduction of medication are shared across the care home.
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http://dx.doi.org/10.1002/gps.4322DOI Listing
March 2016