Innovation and Research

About ENHANCE

This is the website for a research project entitled: ‘Older adult forensic mental health patients: defining barriers, facilitators and ‘what works’ to enable better quality of life, health and wellbeing, reduced risk, and lower levels of security’. The project will be known as ENHANCE.

ENHANCE  is being carried out by Dr Chris Griffiths, Dr Kate Walker, Dr Jen Yates, Professor Tom Denning, Professor Birgit Völlm, Dr Vincent Egan, and Andrew Lowe, between September 2019 and May 2021. It is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1217-20028).

Why are we doing this research?

Forensic psychiatric services work with people with mental illness and who pose a risk to themselves or others deemed sufficiently high to require confinement to secure facilities, or risk assessment and management in the community. Specialist forensic inpatient services are also required specifically for older adults experiencing mental disorder who pose a risk to themselves or others and their needs and requirements are likely to have changes as they have aged.  Older forensic psychiatric patients (defined as aged 55 or over) typically have complex histories having experienced many different types of trauma such as childhood neglect/abuse, substance abuse, poor health self-management, psychiatric admission, homelessness and violence. It has also been found that due to common histories that include poor health management and substance abuse, people with long term mental health disorders experience the challenges associated with old age earlier, and have significantly reduced life expectancy. It is important that psychiatric services offer suitable and appropriate treatment to all patients to enable recovery and better levels of health, wellbeing and quality of life and lower levels of risk to themselves and others. However, it is not known if this is being achieved with older forensic mental health patients, or what the barriers and facilitators to progress are for this group. We know that there is an increasing proportion of older people in secure settings now, but we are unclear how well and effective treatments are with this group of people. The aim of this project is therefore to discover this by undertaking research with service users and service providers, in order to get an in-depth understanding of their needs, requirements, and an insight in to what works for these patients to enhance their quality of life and reduce risk to themselves and others. The research will be used to make recommendations and to inform service provision and policy.

What are our research questions?

R1. What are the levels of wellbeing, recovery related quality of life, cognitive functioning, and health related quality of life in older (aged 55 and over) secure inpatients and those based in the community and how can this inform development of adequate service to address their needs?

R2. From a staff and patient perspective, what are the barriers and facilitators to progress in terms of quality of life, health, wellbeing, risk and lower levels of security? How can these barriers be addressed to facilitate progress?

R3. From a staff and patient perspective, what interventions do and do not work, how, when, why and for who to enhance progress in terms of quality of life, health, wellbeing, risk and lower levels of security?

How will we do it?

Over 20 months, we will work with advisory teams, service users, service providers, and with members of the public, in order to better understand the needs and requirements of older forensic mental health patients. We will do this in four main ways:

STEP 1

Firstly, we will look at existing research and bring it all together to see what it says about service provision and interventions for older forensic mental health patients. This will help guide our research focus and the questions we ask. We will also undertake a policy review to understand what is already in place for older forensic mental health patients.                                                                                                               

STEP 2

With their consent we will interview 36 service users, from high, medium and low risk units as well as those in the community. We will:

• Ask about their wellbeing, recovery related quality of life, cognitive functioning, and health related quality of life;
• Question them on their experiences of service provision and interventions, what they feel works and what does not work, and their views and perceptions on what helps and hinders their progress;
• Examine their case files for background information; and
• Ask them to fill in some questionnaires about quality of life, health and wellbeing in order to understand the characteristics and contextual factors associated with this population.

Alongside this we will also interview 35 people who provide service and/or care for older forensic mental health patients, e.g., psychiatrists, psychologists, nursing staff, social workers, and occupational therapists. We will ask them from their perspective what are the barriers and facilitators to progress in terms of quality of life, health, wellbeing, risk and lower levels of security, and their views about service provision and interventions. This will give us multiple perspectives across different settings.

STEP 3

We will analyse all the data that we have collected from service users and service providers. We will work with our advisory panels to analyse, interpret and write up the findings from the research.

STEP 4

The final phase of our project will bring the various threads together and identify key ‘messages’ from the findings. We will share these with those who: commission services for older forensic mental health patients; deliver day-to-day services; work with this population; and who could benefit from understanding the needs and requirements of this population. We will deliver this in various ways such as through journal articles and reports, conferences and workshops, and roadshows and exhibitions.

So why?

There is very limited research around the experience and the added challenges of ageing in secure forensic psychiatric settings. This is the first UK-based study to examine in detail the barriers and facilitators to progress for older forensic mental health patients, and understand well being recovery and quality of life. The increasing prevalence rates, the longer stay in secure care and the preliminary evidence around the unique barriers to recovery experienced by older patients require that this research is conducted. The proposed research is timely to inform service guidance and standards and decisions on future service design and funding.