Alexander J. Scott

Background: Sleep disturbances are highly prevalent in people with mental health difficulties and are now recognised as a causal, transdiagnostic treatment target. Yet, despite strong evidence, sleep interventions remain underused in routine care. To increase uptake, a comprehensive understanding of the barriers and facilitators is needed to inform the development and implementation of more suitable interventions. Method: We conducted a mixed-methods systematic review following PRISMA guidelines. Data were synthesised using a triangulated, convergent integrated approach and mapped to the Theoretical Domains Framework (TDF). Results: Nineteen studies (n = 1,988) identified 167 barriers and 141 facilitators across all 14 TDF domains, indicating a complex and multifaceted implementation challenge, with Environmental Context and Resources most prominent (65 barriers, 39%). Within this domain, professionals emphasised service-level constraints (e.g. time, workforce constraints), whereas patients highlighted intervention burden and unsuitable home environments. Beyond this, barriers were most commonly coded to beliefs about capabilities, social influences, beliefs about consequences, and knowledge. Patient and professional accounts differed in emphasis, and we provide a detailed, triangulated synthesis across perspectives and TDF domains, highlighting themes such as low perceived control over sleep, uncertainty around responsibility for sleep, and limited social and organisational support for delivery. Conclusions: This review is the first to highlight that barriers to implementing sleep interventions are shaped primarily by environmental context and resources, alongside key psychological determinants of engagement across both patients and professionals. In response, we identify five core principles to guide the development and implementation of sleep interventions in mental health settings.

Almost all societal grand challenges, whether concerning the environment, health, well-being, or the development of sustainable economic models, have at their heart a need to understand people’s behaviour. However, uniting data and insights across disparate fields requires an explicit and shared understanding of concepts, variables, and ideas (e.g., how to characterise and differentiate behaviours). Ontologies provide a mechanism for creating this explicit and shared understanding and are starting to be developed and used in the social and behavioural sciences. This paper proposes an online co-design approach to use and develop ontologies of behaviour to specify the characteristics of behaviour (e.g., habitual, changeable, effortless) and studies that investigate behaviour as part of a project designed to understand how behaviours are related. We report on our experience of collaborative co-development of ontologies using real-time interactive tools and reflect on the benefits and challenges of our approach. We also offer a set of recommendations for researchers interested in applying such methods to co-develop ontologies. The work contributes to efforts to understand the characteristics of behaviour and enable these to be used to understand questions about behaviour (e.g., is poor sleep associated with greater engagement in habitual behaviours?).

Background: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive–behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive–behavioural therapy principles but has a shorter treatment period.Objective: This research investigated the non-inferiority of one-session treatment to cognitive–behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined.Design: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations.Settings: There were 26 sites, including 12 NHS trusts.Participants: Participants were aged 7–16 years and had a specific phobia defined in accordance with established international clinical criteria.Interventions: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive–behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation.Main outcome measures: The primary outcome measure was the Behavioural Avoidance Task at 6 months’ follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children’s Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale.Results: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive–behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive–behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive–behavioural therapy compared with one-session treatment –0.123, 95% confidence interval –0.449 to 0.202 (intention to treat), mean difference –0.204, 95% confidence interval –0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive–behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive–behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment.Limitations: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up.Conclusions: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive–behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways.Trial registration: This trial is registered as ISRCTN19883421.Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.

Between 2015 and 2020 the Alleviating Specific Phobias Experienced by Children Trial (ASPECT) was conducted in the UK to examine the non-inferiority of One-Session Treatment in comparison to Cognitive Behavioural Therapy based interventions for children and young people with specific phobias. A nested qualitative evaluation was conducted as part of this trial to examine the acceptability of One-Session Treatment. Qualitative interviews were conducted with children and young people taking part in the trial, their parents/guardians, and clinicians delivering the intervention, about their experiences and the acceptability of One Session Treatment. Interviews were digitally recorded and transcribed verbatim. Analysis followed a qualitative framework approach, a widely used method of analysing primary qualitative data pertaining to healthcare practices with policy relevance. Stakeholder groups found One Session Treatment to be an acceptable intervention and barriers and facilitators for its implementation into services were also identified. Potential barriers included challenges to patient flow and treatment scepticism, whilst facilitators included adopting a child-centred approach, child readiness and suitability, opportunity for increased momentum, parental support and involvement, and proximal and distal gains. For One Session Treatment’s successful implementation into services, consideration of these barriers is needed and suitability guidance for its use in this population should be developed. Further research exploring children and young people’s experiences of receiving Cognitive Behavioural Therapy and its acceptability in comparison to One Session Treatment would be welcomed.

Background: 5%–10% children and young people (CYP) experience specific phobias that impact daily functioning. Cognitive Behaviour Therapy (CBT) is recommended but has limitations. One Session Treatment (OST), a briefer alternative incorporating CBT principles, has demonstrated efficacy. The Alleviating Specific Phobias Experienced by Children Trial (ASPECT) investigated the non‐inferiority of OST compared to multi‐session CBT for treating specific phobias in CYP. Methods: ASPECT was a pragmatic, multi‐center, non‐inferiority randomized controlled trial in 26 CAMHS sites, three voluntary agency services, and one university‐based CYP well‐being service. CYP aged 7–16 years with specific phobia were randomized to receive OST or CBT. Clinical non‐inferiority and a nested cost‐effectiveness evaluation was assessed 6‐months post‐randomization using the Behavioural Avoidance Task (BAT). Secondary outcome measures included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety Depression Scale, goal‐based outcome measure, and EQ‐5DY and CHU‐9D, collected blind at baseline and six‐months. Results: 268 CYPs were randomized to OST ( n = 134) or CBT ( n = 134). Mean BAT scores at 6 months were similar across groups in both intention‐to‐treat (ITT) and per‐protocol (PP) populations (CBT: 7.1 (ITT, n = 76), 7.4 (PP, n = 57), OST: 7.4 (ITT, n = 73), 7.6 (PP, n = 56), on the standardized scale‐adjusted mean difference for CBT compared to OST ‐0.123, 95% CI −0.449 to 0.202 (ITT), mean difference −0.204, 95% CI −0.579 to 0.171 (PP)). These findings were wholly below the standardized non‐inferiority limit of 0.4, suggesting that OST is non‐inferior to CBT. No between‐group differences were found on secondary outcomes. OST marginally decreased mean service use costs and maintained similar mean Quality Adjusted Life Years compared to CBT. Conclusions: One Session Treatment has similar clinical effectiveness to CBT for specific phobias in CYP and may be a cost‐saving alternative.

There have been increased calls to manage poor sleep in Inflammatory Bowel Disease (IBD) care. However, it’s unclear how people with IBD perceive their sleep to fit within their experience of IBD and whether interventions to improve sleep are acceptable. This qualitative study found that people with IBD perceive their sleep to be an integral part of living with IBD, would like more sleep support than is currently available, and find interventions for sleep broadly acceptable. It is important for future research to tailor sleep interventions towards those with IBD and explore the barriers to sleep support in routine care

The extent to which sleep is causally related to mental health is unclear. One way to test the causal link is to evaluate the extent to which interventions that improve sleep quality also improve mental health. We conducted a meta-analysis of randomised controlled trials that reported the effects of an intervention that improved sleep on composite mental health, as well as on seven specific mental health difficulties. 65 trials comprising 72 interventions and N = 8,608 participants were included. Improving sleep led to a significant medium-sized effect on composite mental health (g+ = -0.53), depression (g+ = -0.63), anxiety (g+ = -0.51), and rumination (g+ = -0.49), as well as significant small-to-medium sized effects on stress (g+ = -0.42), and finally small significant effects on positive psychosis symptoms (g+ = -0.26). We also found a dose response relationship, in that greater improvements in sleep quality led to greater improvements in mental health. Our findings suggest that sleep is causally related to the experience of mental health difficulties. Future research might consider how interventions that improve sleep could be incorporated into mental health services, as well as the mechanisms of action that explain how sleep exerts an effect on mental health.

Background: Acute respiratory failure is a life-threatening emergency. Standard prehospital management involves controlled oxygen therapy. Continuous positive airway pressure is a potentially beneficial alternative treatment; however, it is uncertain whether or not this treatment could improve outcomes in NHS ambulance services.Objectives: To assess the feasibility of a large-scale pragmatic trial and to update an existing economic model to determine cost-effectiveness and the value of further research.Design: (1) An open-label, individual patient randomised controlled external pilot trial. (2) Cost-effectiveness and value-of-information analyses, updating an existing economic model. (3) Ancillary substudies, comprising an acute respiratory failure incidence study, an acute respiratory failure diagnostic agreement study, clinicians perceptions of a continuous positive airway pressure mixed-methods study and an investigation of allocation concealment.Setting: Four West Midlands Ambulance Service hubs, recruiting between August 2017 and July 2018.Participants: Adults with respiratory distress and peripheral oxygen saturations below the British Thoracic Society’s target levels were included. Patients with limited potential to benefit from, or with contraindications to, continuous positive airway pressure were excluded.Interventions: Prehospital continuous positive airway pressure (O-Two system, O-Two Medical Technologies Inc., Brampton, ON, Canada) was compared with standard oxygen therapy, titrated to the British Thoracic Society’s peripheral oxygen saturation targets. Interventions were provided in identical sealed boxes.Main outcome measures: Feasibility objectives estimated the incidence of eligible patients, the proportion recruited and allocated to treatment appropriately, adherence to allocated treatment, and retention and data completeness. The primary clinical end point was 30-day mortality.Results: Seventy-seven patients were enrolled (target 120 patients), including seven patients with a diagnosis for which continuous positive airway pressure could be ineffective or harmful. Continuous positive airway pressure was fully delivered to 74% of participants (target 75%). There were no major protocol violations/non-compliances. Full data were available for all key outcomes (target ≥ 90%). Thirty-day mortality was 27.3%. Of the 21 deceased participants, 14 (68%) either did not have a respiratory condition or had ceiling-of-treatment decision implemented that excluded hospital non-invasive ventilation and critical care. The base-case economic evaluation indicated that standard oxygen therapy was probably cost-effective (incremental cost-effectiveness ratio £5685 per quality-adjusted life-year), but there was considerable uncertainty (population expected value of perfect information of £16.5M). Expected value of partial perfect information analyses indicated that effectiveness of prehospital continuous positive airway pressure was the only important variable. The incidence rate of acute respiratory failure was 17.4 (95% confidence interval 16.3 to 18.5) per 100,000 persons per year. There was moderate agreement between the primary prehospital and final hospital diagnoses (Gwet’s AC1 coefficient 0.56, 95% confidence interval 0.43 to 0.69). Lack of hospital awareness of the Ambulance continuous positive airway pressure (CPAP): Use, Treatment Effect and economics (ACUTE) trial, limited time to complete trial training and a desire to provide continuous positive airway pressure treatment were highlighted as key challenges by participating clinicians.Limitations: During week 10 of recruitment, the continuous positive airway pressure arm equipment boxes developed a ‘rattle’. After repackaging and redistribution, no further concerns were noted. A total of 41.4% of ambulance service clinicians not participating in the ACUTE trial indicated a difference between the control and the intervention arm trial boxes (115/278); of these clinician 70.4% correctly identified box contents.Conclusions: Recruitment rate was below target and feasibility was not demonstrated. The economic evaluation results suggested that a definitive trial could represent value for money. However, limited compliance with continuous positive airway pressure and difficulty in identifying patients who could benefit from continuous positive airway pressure indicate that prehospital continuous positive airway pressure is unlikely to materially reduce mortality.Future work: A definitive clinical effectiveness trial of continuous positive airway pressure in the NHS is not recommended.Trial registration: Current Controlled Trials ISRCTN12048261.Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 25, No. 7. See the NIHR Journals Library website for further project information.