Mental Health National Service Framework (Wales) edition

Health Evidence Bulletins - Wales

Mental Health




1. Promoting Social Inclusion

2. User and Carer Empowerment

3. Promotion of Opportunities for a Normal Pattern Of Daily Life

4. Equitable, Accessible Services

5. Commissioning Effective, Comprehensive and Responsive Services

6. Delivering Effective, Comprehensive and Responsive Services

7. Effective Client Assessment and Care Pathways

8. Ensuring A Well Staffed, Skilled And Supported Workforce


The original series Protocols for Investment in Health Gain were written in the early 1990s to suggest areas where the introduction, or more widespread use, of certain practices could lead to worthwhile improvements in health for the people of Wales. Subsequently, the Health Evidence Bulletins Wales (HEBW) projecti was instigated in 1996 to review these documents and provide summaries or statements of the best current evidence with a precise indication of the strength of the evidence and its sources for each statement.

The first HEBW Mental Health Bulletinii focused on bringing together evidence for the effectiveness of largely medical and health service interventions for selected disorders. This Bulletin was developed specifically to support the implementation of the Wales National Service Framework (NSF) for Adult Mental Health Services in Walesiii and has been structured to support the updated NSFiv. Topics include mental health promotion and social inclusion, the needs of service users and carers, access to services, provision of comprehensive assessment and treatment, and recruiting and maintaining a skilled workforce. In accordance with the NSF, the Bulletin also links to issues for children’s mental health services, services for elderly people with a mental illness, drug and alcohol misuse provision and those with mental health problems in the criminal justice system.

The statements represent a methodical summary of the evidence in this area identified through a formal literature search across a wide range of sources. The evidence has been critically appraised using internationally accepted methods, summarised and compiled into this document and reviewed by a multidisciplinary teamv. The information in this document and the Project Methodology are also available electronically, via the Health of Wales Information Service ( and the Internet (

The convention used in this document to indicate the type of evidence isvi:

‘Type I evidence’ - at least one good systematic review
(including at least one randomised controlled trial).
‘Type II evidence’ - at least one good randomised controlled trial
‘Type III evidence’ - well designed interventional studies without randomisation
‘Type IV evidence’ - well designed observational studies
‘Type V evidence’ - expert opinion; influential reports and studies

The use of evidence type rather than evidence hierarchy has been chosen deliberately. Every attempt has been made to find the best available evidence within each topic. Information from high quality intervention studies is included whenever possible but observational evidence also cited where relevant. By valuing evidence from randomised controlled trials more highly than observational studies there is a danger that intervention with limited effectiveness might be judged more worthy than those based on observation. Similarly, those observational studies that clearly prove effectiveness (and make a randomised trial unethical) might be undervalued.

In addition, qualitative research can be more appropriate for interventions designed to influence human behaviour, providing insights into people’s experiences and into the social contexts that strengthen, support or diminish behaviour.

Information assigned as Type V evidence may include expert opinion and important reports or recommendations that should also be highly regarded.

Statistically significant quantitative information has been provided where possible using the units of measure provided in the cited publication(s). For guidelines, an indication is given as to whether they are based on a systematic review (evidence based guidelines) and/or developed via the consensus of an expert panel (expert consensus guidelines).  

The following information sources were systematically searched in the preparation of this Bulletin: ASSIA, AMED, Caredata, CINAHL, Clinical Evidence, Embase, Evidence Base, EBM Reviews (including the Cochrane Library), HMIC, Medline, National Institute for Clinical Evidence (NICE), National Research Register, PsycINFO, SIGLE, TRIP, SIGN Guidelines, Sociological Abstracts, and Web of Knowledge. Internet websites such as the Department of Health, and specialist Societies and Colleges (e.g. Sainsbury Centre for Mental Health, The Royal College of Psychiatrists) were also searched.

Search filters were used to search for systematic reviews and randomised controlled trials across all topic areasv. Randomised controlled trials with less than 100 participants were normally excluded unless a smaller trial was the best available evidence within a subject area. Specific searches for all types of evidence were then carried out for topics where evidence from randomised controlled trials was not available or feasible.

A comprehensive literature search, to identify recent reliable evidence across all topics, was carried out covering publications from 2000 to November 2003. Update searches were performed in the Cochrane Database of Systematic Reviews 2004 Issue 4 for all topics. In addition, selected information sources from the list above were searched during November and December 2004 for certain topics as advised by reviewers of the Bulletin. Full details of all the search strategies used are available from the Project Office.vii

This Bulletin is designed to summarise the best current evidence to support the development of implementation tools such as guidelines and care pathways at national and local levels. It is also anticipated that the document will be of interest to students, educators and healthcare professionals, in keeping abreast of the large and increasing body of literature in this field. Some of the conclusions reached in this Bulletin will inevitably be controversial. Every effort has been made to include the best evidence within a subject area. Readers who are aware of any important studies that have been overlooked are encouraged to contact the project teamvii

While every effort is made to avoid errors in these summaries, the statements are intended to act as signposts to reliable sources of evidence, not as guidelines for the management of patients. It is hoped that this Bulletin will facilitate evidence-based practice, which involves “integrating individual expertise with the best available external evidence from systematic research”viii


ii Health Evidence Bulletins - Wales: Mental Health. Cardiff: Welsh Office, 1998 [accessed 01.11.05]

iii Adult Mental Health Services. A National Framework for Wales. Cardiff: Welsh Assembly Government, April 2002. [accessed 16.05.05]

iv ‘Raising The Standard’ The Revised Adult Mental Health National Service Framework and an Action Plan for Wales. Cardiff: Welsh Assembly Government, October 2005  [accessed 01.11.05]

v Weightman AL, Mann MK, Sander L,Turley RL. Health Evidence Bulletins Wales. Project Methodology 5. Cardiff: Information Services University of Wales College of Medicine, January 2004 [accessed 01.11.05]

vi This table is adapted from the Bandolier system (derived from the work at McMaster University, Canada) using the Centre for Reviews and Dissemination criteria for a systematic review. See [accessed 01.11.05] and the Database of Abstracts of Reviews of Effectiveness (DARE) [accessed 01.11.05]

vii Health Evidence Bulletins Wales. Information Services. Cardiff University, Cardiff CF14 4XN. Email:

viii Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. How to Practice and Teach EBM Edinburgh: Churchill Livingstone, 1997.


Glossary of Abbreviations used in this Bulletin 

ACCESS Access to Community Care and Effective Services and Supports
ACT   Assertive Community Treatment
ASAP Assaulted Staff Action Programme
BDI   Beck Depression Inventory
BPD   Borderline Personality Disorder
CAMHS Child and Adolescent Mental Health Services
CBT   Cognitive Behavioural Therapy
CI  Confidence interval
CISM Critical Incident Stress Management
CMHT   Community Mental Health Tea
CPA Care Programme Approach
CPN   Community Psychiatric Nurse
COAST Croydon Outreach and Assertive Support Team
COPES Community Oriented Program Environmental Scale
DLRR DerSimonian – Laird Relative Risk
DSH Deliberate Self Harm
EPDS Edinburgh Postnatal Depression Scale
ESS Ethnic Specific Services
FSW Family Support Worker
GAD General Anxiety Disorder
GAF Global Assessment of Functioning
ICM      Intensive Case Management
ICT Information and Computing Technologie
ID Intellectual disability
IPS Individual Placement and Support
LQOLP Lancashire Quality of Life Profile
MDOs Mentally Disordered Offenders
MHS  Mental Health Service
MHWs Mental Health Workers
NICE    National Institute for Clinical Excellence
NNH    Number Needed to Harm
OCD   Obsessive Compulsive Disorder
OR    Odds Ratio
PANSS Positive and Negative Syndrome Scale
PCP Primary Care Practitioner
PTSD Post Traumatic Stress Disorder
QOL     Quality of Life
RCT Randomised Controlled Trial
RR  Relative Risk
SD Standardised Difference
SDQ      Strengths and Difficulties Questionnaire
YBOCS Yale-Brown OCD Scale
YOT   Youth Offending Team



Health Evidence Bulletins Wales, Support Unit for Research Evidence, Cardiff University.E-mail: