Impact case study database

In the UK, roughly a million people go through courts and around four million people are affected by crime each year. Following the discovery that up to 50% of the UK prison population has some form of TBI, that young offenders have TBI at five times the rate of normal population, and that the associated behaviours produce a highly vulnerable group of people, Williams has spent several years engaging with policy makers to ensure the justice system accounts for Traumatic Brain Injury. With national (England and Wales) and global (via the UN) reach, this highly engaged body of work has: 1) placed neurodisabilities (ND) and TBI on the agenda of judicial systems; 2) led to major restructuring of judicial policies for minors; 3) led to mandatory ND screening, enhanced support, and staff training for adult prisons; and 4) implemented new sentencing guidelines to account for ND.

Placing Neurodisabilities (ND) and TBI on the agenda of judicial systems

The work of Williams and colleagues has been instrumental in placing TBI as a key focus for judicial policy makers. For example, England’s Director of Health and Justice NHS Justice, confirms:

“The research by Williams and colleagues demonstrated that there was a very high level of traumatic brain injury (TBI) in prison populations, and, that it was associated with early and repeated violence and mental health issues - particularly suicidality….As a health condition, TBI, therefore became an important focus for the judicial system.” [ 5.1].

This, she explains, has led to changes throughout the entire system, prompting the re-design of services that integrate trauma-informed perspectives into policies around crime [ 5.1].

In 2017, the NICE guidelines on Mental Health of Adults in the Criminal Justice System were updated to include provisions around TBI [ 5.2]. Williams, drawing on insights gained through his body of research, received specific acknowledgement of his provision of expert testimony to the guidance committee [ 5.2]. The new recommendations covered all occasions where individuals come into contact with the criminal justice system and highlighted the need for staff training on TBI issues, provisions for the recognition and assessment of TBI via a ‘Head Injury’ screening at custody reception, and recommendations on ensuring appropriate interventions particularly in relation to managing suicide risk [ 5.2].

Responding to evidence from Williams a review of the UN Convention on the Rights of the Child in Justice settings concluded that children with neurodisability (ND) should not only have their needs met whilst detained, but should not be made at risk of being imprisoned in the first place [ 5.3]. The new convention states:

“Children with developmental delays or neurodevelopmental disorders or disabilities... should not be in the child justice system at all, even if they have reached the minimum age of criminal responsibility.”

They recommend the 187 signatory member states of the convention support children and young people with ND to be enabled to be in society (2019) [ 5.3].

Major restructuring of judicial policies for minors

All young people (under 18) in custody (~3,000/year) in England and Wales are now assessed and treated for TBI and other neurodisabilities (ND) [ 5.4]. England’s NHS Justice, with Williams as an advisor [ 5.1], adopted a ‘Secure Stairs Model’ for Young Offender Institutions, to provide therapeutic resources for those who are classified as vulnerable, including those with ND and TBI. The model was launched by NHS England in 2018 [ 5.5] and represented a move towards integrated healthcare and rehabilitation in the prison system that creates a better environment for rehabilitation success. England’s Director of Health and Justice confirms the paradigm shift it represents, stating that the programme is being implemented across England,

“to replace traditional incarceration…to ensure that children and young people are provided with therapeutic community approaches informed by evidence base on trauma and neuro-disability” [ 5.1].

Led to mandatory ND screening, enhanced support, and staff training for adult prisons

In adult prisons, it is now mandatory to screen for TBI, provide key-workers, and train staff to identify and support brain injury issues. Exeter worked closely with the All Party Parliamentary Group on Acquired Brain Injury and their recommendations led to all prisons conducting mandatory screening for TBI, confirmed by the both the Secretary of state and the Under-secretary of state for Justice & Lord Chancellor [ 5.4]. This change impacts 83,000 (Offender Management Statistics Bulletin, England and Wales, ONS) currently sentenced prisoners and approximately 60 000 entrants into the criminal justice system each year. In addition, specialist health referrals to assess for TBI are now made when a prisoner displays symptomatic behaviour, to determine appropriate treatment pathway, where previously a personality disorder diagnosis would have been made [ 5.4].

Drawing on evidence from Williams and his team, the UK parliament’s Justice Select Committee [ 5.6] concluded the need for wholesale reform of the prison system to reduce violence and manage suicide risk in young adults. Their recommendations focused on restorative justice and trauma-informed approaches, which included accounting for TBI and the development of appropriate support systems such as specialised link workers piloted by the Exeter Team [ 5.4].

In response to the recommendations from the Justice Select Committee, the Ministers of Prisons, implemented measures to ensure, ‘[ a]ll civil, remand and sentenced people in prison will have a dedicated prison key worker’ by March 2019 [ 5.7 p.5-6] and funding for this initiative has been received by ten prisons so far [ 5.4].

In 2020 the Ministry of Justice confirmed the extent to which Acquired Brain Injury (which includes TBI) has now been integrated into the justice system [ 5.4], in part a response to recommendations set out by a report [ 5.4] authored by Williams and colleagues. The Under Secretary of State for Justice, explains,

“Individuals with ABI are within scope for NHS England’s Liaison and Diversion (L&D) services, which provide assessments and referrals to support for vulnerable people in contact with the criminal justice system. L&D services have been rolled out across police custody suites and magistrates courts in England… [and there is a] similar system in Wales” [ 5.4].

Furthermore, basic awareness training on Acquired Brain Injury (ABI) is now included in the Prison Officer Entry Level Training, “providing all new prison officers with an overview of what an ABI is, what may cause it, and what symptoms might result from it” [ 5.4].

Implemented new national and global sentencing guidelines to account for ND

Sentencing guidelines in England and Wales now recommend that judges account for developmental maturity and TBI. The Sentencing Guidelines were updated first in 2017, and again in 2020, incorporating evidence from Prof Williams, to account for “Any experiences of brain injury or traumatic life experience (including exposure to drug and alcohol abuse) and the developmental impact this may have had” [ 5.8]. The latest Sentencing Guidelines have added Acquired Brain Injury to the list of mental health disorders to consider in sentencing, confirming recognition of ABI and TBI in the criminal Justice system [ 5.8].

Furthermore, the UN office on Drugs and Crime requested Williams become an advisor to develop new guidelines for judges worldwide to account for developmental maturity and TBI. The 2018 and 2019 manuals [ 5.9] created urge judges in the UN’s 187 signatory states to consider how brain injury and trauma contribute to crime and the need to address neurological disorders and development to reduce future crimes. When reflecting on the growing awareness of TBI issues throughout the justice system, the former Chief Inspector of Prisons says the following:

“I can only say that the transformation in understanding is remarkable. For this I give most credit to Professor Williams, whose research is not only highly regarded by Ministers and officials…It is the best example I know of academic research leading to positive results in terms both of policy and practice” [ 5.10].

More than 300 million people worldwide and 3 in 100 in England experience clinical depression, with chronic and recurring forms of the illness causing not only individual suffering but detrimental economic and social impacts. In the UK, as elsewhere, the health system has for decades relied on prescribing medication for treating depression. Although effective in symptom management and for preventing relapses, antidepressants often have to be taken over years, representing a substantial and growing financial burden for the NHS (e.g.70.9 million prescriptions were written for antidepressants in 2018 in UK compared to only 36 million prescriptions in 2008). At the same time, medications can be accompanied by undesirable side-effects, such as addiction and withdrawal symptoms, and many patients prefer psychological therapies instead.

Over the past twenty years, interest has been growing in the potential for mindfulness-based cognitive therapy (MBCT) as a non-pharmaceutical alternative for the treatment of depression and depressive relapse prevention. However, before the Exeter research, it was unknown whether MBCT could be effective as a stand-alone treatment in the NHS and how it could be rolled out to treat large numbers of patients. The Exeter research filled this knowledge gap, leading to five distinct and beneficial impacts: changes in policy and clinical guidelines; improved clinical training and practice; greater access to MBCT; enhanced patient experience and outcomes; and cost savings for the NHS and wider society. Each impact is detailed below.

Changes in UK and worldwide mental health policies and clinical guidelines for depression/mood disorders

Exeter’s research [3.2] was referenced by the Mindfulness All-Party Parliamentary Group who recommended group-based MBCT for depressive relapse in their 2015 report Mindful Nation UK, [5.1] and it will also be recommended in the updated version of Depression in adults: treatment and management, [5.2] guidelines which will be published in 2022 by NICE. The lead of the NICE Depression Guideline Development Group confirms that “ Exeter’s work was vital in understanding how MBCT could be successfully implemented in psychological services, providing an effective alternative to antidepressant medication to those suffering from recurrent depression. This has directly led to the inclusion of MBCT in the NICE Guidelines on Depression as a recommended intervention for relapse prevention.” [5.3]

Significance:* Prior to the Exeter research, policy and clinical guidelines in the UK for depression treatment and relapse prevention did not prioritise MBCT. Exeter’s work has led to policy makers and clinicians in the UK and overseas promoting MBCT for the first time.

Reach:* Up to 15% (87,000) of the patients suffering from depression and being at risk for relapse across the UK [5.1, see page 5 for example ] will benefit from the new policies and guidelines influenced by Exeter’s work. The policy impacts extend overseas too: MBCT for depression treatment and relapse prevention is now recommended by the American Psychological Association, one of the largest professional organisations worldwide, with Exeter research [3.3] cited in its treatment guidelines [5.4]. Similarly, MBCT is now recommended in the national clinical guidelines for relapse prevention in Canada, Australia and New Zealand, [5.4] and again Exeter’s research is cited [3.1], [3.2] and [3.3].

Improved access to MBCT in routine clinical services

As well as influencing policy, since 2014, Exeter has worked closely with IAPT (Improving Access to Psychological Therapies), the key national treatment provider for depression and anxiety disorders in England, to improve access to MBCT for patients with depression.

Reach:* To date, MBCT has been implemented in about 40% of IAPT services, encompassing 63 NHS Trusts, across England and, between 2015 and 2020 West IAPT staff were trained in MBCT at Exeter, which informed the development of a national programme in 2016/17 (funded by NHS England) when Exeter partnered with four other mindfulness centres across the UK to deliver MBCT IAPT training: London and South East Sussex Mindfulness Centre, North Oxford Mindfulness Centre, Centre for Mindfulness Research and Practice (Bangor University), Midlands and East Nottingham Centre for Mindfulness (Nottinghamshire Healthcare NHS Foundation Trust) and the MBCT Training Programme in Tees Esk and Wear Valley NHS Foundation Trust. As of autumn 2020, 154 IAPT staff have been trained nationally, of those 100 in Exeter alone, each with a capacity to deliver MBCT to approximately 50 or more patients per year . It is anticipated that a further 80 MBCT therapists will be trained. [5.5]

Significance:* Exeter researchers are directly responsible for the increased access to MBCT in the southwest and nationally. The Programme Director of IAPT training until August 2020, confirms that: “…as a result of the PREVENT research conducted at the University of Exeter on MBCT, we have been able to train and partner with other organisations to train IAPT therapists in MBCT across both the South West and the whole of England” [5.5], has benefitted a total of 10,453 patients, [5.10] with up to an additional 44000 projected to be receiving MBCT by 2024. From 2024, the level of access is likely to ramp up still further because IAPT aims to double its current reach to 1.9 million patients by 2023/24. Conservatively, that would equate to between 5,000 and 10,000 patients who could receive MBCT every year across the country [prediction based on NHS Mental Health Implementation Plan 2019/20 – 2023/24, published July 2019, page 23].

Improved clinical practice by uniform national professional training curriculum for MBCT and training of mental health practitioners in the NHS

MBCT is a complex approach that needs to be delivered well to gain full benefit. Through online and in-person training, Exeter researchers have directly influenced the improvement of the standard of professional training for clinicians practising, or seeking to practise, mindfulness-based interventions. In 2016 Exeter researchers influenced and contributed to the development of a new national MBCT professional training curriculum for IAPT staff. [5.6] In tandem with Bangor University, Exeter researchers developed online training resources and assessment materials [3.4] which are freely available to MBCT practitioners for continuing professional development (http://www.implementing\-mindfulness.co.uk\). The CBT Lead for West Dorset branch of the British Association for Behavioural and Cognitive Psychotherapies, completed the Exeter University IAPT mindfulness teaching pathway in 2014. They have since treated over 300 patients who are showing improvement in line with national data and experiencing continued positive mental health. “I have access to Exeter’s online training resources and assessment materials so I may continue to update my practice and refer back to at any time, strengthening my skills and abilities to help this population.” [5.7] Exeter researchers (in collaboration with Bangor and Oxford) have also developed and validated a new tool, MBI: TAC (Mindfulness-Based Interventions: Teaching Assessment Criteria), for assessing the teaching competence and programme adherence of MBCT practitioners during professional training. The tool has improved training quality standards for mindfulness practitioners, ultimately enhancing patient care. [5.8]

Significance:* Exeter’s work has influenced the Professional training standards of MBCT across the UK and beyond.

Reach:* To date 154 practitioners in the UK have directly or indirectly benefited from training in MBCT provided by Exeter researchers. [5.5] In addition, MBCT training materials have been accessed by health care practitioners from around the world (a list of practitioners from around the world is available at https://www.accessmbct.com\).

Improved outcome and patient experience

MBCT has sustained recovery in most of those not currently depressed and contributed to clinical improvement and recovery in half of those currently depressed. Testimonies from patients in Exeter’s Accessing Evidenced Based Psychological Therapies (AccEPT) clinic demonstrate the profound impact of MBCT, one attendee stating: “ I am delighted to confirm that I found the MBCT course to be extremely beneficial. I can honestly say that it changed my life for the better. I had learned how to become aware of my current mood and when this was deteriorating, to make use of the mindfulness practice to get myself on an even keel again.” [5.9]

Significance: Patient outcomes, at both local and national level, have been significantly boosted by MBCT. Since 2014, 888 patients have received the therapy within Exeter’s AccEPT clinic. Since 2014, three audits have revealed between 64-75% of these patients showed reliable improvement and 50-51% met criteria for reliable recovery. [5.10] Similar outcomes have been recorded at the national level; in a 2018/19 annual report the NHS found that about 50% of 3,957 patients receiving MBCT (of whom 1,566 reported current depression) fully recovered and 50% showed significant clinical improvement. [5.11]

Reach:* As noted above, with national access to psychological treatments expected to double, the benefits of MBCT – currently enjoyed by over 10,000 people suffering from depression in the UK – are likely to reach 20-40,000 patients by 2024 [prediction based on NHS Mental Health Implementation Plan 2019/20 – 2023/24, published July 2019, page 23].

Benefits for the NHS and society

In the last 10 years the number of annual prescriptions for antidepressant medication has doubled to 70 million, and today antidepressants cost the health service an estimated £5.5 million every week. At a one-off cost of £112 per person [3.2], MBCT can be cheaper than long-term antidepressant maintenance medication (median of £49.69/year with a treatment time of 3-5 years), as well as alternative individual psychological treatments for depression, such as cognitive therapy (£334/person). Further, 87% of patients receiving MBCT were able to reduce or taper off their medication [3.2] suggesting that this therapy will yield substantial cost savings for the NHS, and for wider society, particularly when treatment adherence is accounted for.

Significance:* Long-term cost estimation models accounting for treatment adherence (around 80% for MBCT versus 45% for antidepressant medication), identified MBCT as more economical than maintenance antidepressant medication, with approximately £1,300 lower costs over a 24-month time horizon, and 0.08 higher quality-adjusted life years (QALYs) [see Pahlevan, T., et al. (2020) Cost-Utility Analysis of Mindfulness-Based Cognitive Therapy versus Antidepressant Pharmacotherapy for Prevention of Depressive Relapse in a Canadian Context. Can J Psychiatry 65(8): 568-576]. Furthermore, MBCT offers cost savings for wider society, in the form of, among others, improved long-term physical health, reduced suffering, improved daily functioning (work, parenting, interpersonal relationships) and enhanced participation in and enjoyment of life. Based on Layard et al.’s cost benefit analysis of psychological therapies in general, this cost saving for the society can be estimated at £19.98 million [see Layard et al. (2007) Cost-benefit analysis of psychological therapy. National Institute Economic Review, 202 (1). 90 -98].

Reach:* When prescribed as an alternative to antidepressant medication MBCT has the potential to cut costs wherever implemented in the NHS, assuming practitioners are effectively trained.

The discovery of the previously unknown phenomenon of the glass cliff by Ryan and Haslam has continued to have a demonstrable impact in changing the vocabulary, understanding, and public discourse around the precarious positions that women and other minority group members are often put into when given senior appointments. Key to this impact, the glass cliff has noticeably shifted public discussion of female leaders from a critique of their poor performance - which is a form of stereotyping and bias that perpetuates gender inequality - to a more nuanced and complex discussion recognising that woman may be appointed to certain precarious positions which make it more difficult to succeed. Given the current cultural and media climate with regard to women speaking out against discrimination, sexual misconduct, and unequal pay, the public is becoming more aware of inequalities and discrimination that women face. The glass cliff is an invaluable lens through which public discourse can generate a new way of thinking to discuss these injustices. Such a shift in dialogue, both in Britain and internationally, acknowledges ongoing subtle bias faced by senior women in the workplace.

Impact on Public Discourse

Since the glass cliff impact case study was submitted to REF2014, the term ‘glass cliff’ has continued to have an impact on public discourse. While initial media coverage was restricted to reports about the research project, in more recent years this has no longer been the case. The majority of references to the glass cliff now do so without reference to the research itself. Instead, the term has achieved the status of a common phrase used within public discourse to explain women’s leadership. Evidence of the glass cliff impacting on public discourse is best demonstrated by examining the media use of the term. A Google news search for ‘glass cliff’ from January 2014 to March 2020 revealed over 1,245 news articles that refer directly to the glass cliff; the large majority of them in regard to females in leadership roles. The glass cliff has become part of common parlance and an accepted term to use in journalism when describing discrimination against female leaders. A broader phrase search on Google revealed over 101,160 hits (up from 21,000 at 2014REF) and over 642 videos. Some of these hits included the Freakanomics podcast (February 2018; over 2,000,000 downloads/streams) where Ryan was interviewed discussing the glass cliff. The host stated: “ *it would seem the glass cliff is a significant problem with significant ramifications. So: what’s to be done about it? How can more good female executives attain the leadership roles they deserve — and not just at companies that are in crisis mode?*” [5.1].

In 2016 the Oxford English Dictionary counted “glass cliff” as one of their words of the year [5.2]. The word of the year is chosen from a shortlist of words that the Oxford English Dictionary language research program identifies as new and emerging words that “…reflect the ethos, mood, or preoccupations of that particular year and (that) have lasting potential as a word of cultural significance.” The glass cliff Wikipedia page had 394,603 page views since it was created in 2015 and 1,211 #glasscliff trending on Twitter since 1 August 2013, further indicating the term ‘glass cliff’ is not only being used in research and the media but now a commonplace, global word.

Improved media and political recognition of gender discrimination

Political debate has been informed by Ryan and Haslam’s research with news articles citing the glass cliff as plausible explanations for Theresa May’s rise and fall amidst the Brexit crisis, the 2016 and 2020 Presidential Elections [5.3], and women’s political leadership throughout COVID. Articles that utilise the term ‘the glass cliff’ are more likely to recognise the gender bias associated with May’s appointment and are more likely to recognise the difficulty of her position. Those that don’t mention the glass cliff are more likely to focus on her performance (without a context in which to understand it) and thus perpetuate gender stereotypes that women are poor at leadership.

Ryan and Haslam’s research has also been represented worldwide [5.3], including the Huffington Post, the Washington Post, and the New York Times (average 8 million views). The Fast Company cite real-world, global examples of the glass cliff such as the UK and French general election results from 2001, 2005, and 2010 *“…each country’s conservative party tended to support female and minority candidates when conditions weren’t favorable for them to succeed…The implication is that conservatives are deliberately choosing to put women and minorities in these no-win situations in order to have them fail and support the status quo of having white men in power.*” As well as citing examples of women experiencing the glass cliff in the corporate world, such as Carly Fiorina (Hewlett-Packard), Pat Russo (Alcatel-Lucent), Zoe Cruz (Morgan Stanley), Diane Greene (VMware), Dawn Hudson (PepsiCola North America), and Marissa Mayer (Yahoo) [5.4]. During the current Coronavirus pandemic, President Trump has surrounded himself with female advisors, which has gained attention from the media as a potential glass cliff situation.

Impact on Global Discourse on female leadership and empowerment

National and international media have embraced the term glass cliff, incorporating it into analyses of women’s leadership positions. Global news websites [5.5] (The Times, The Guardian) have discussed the glass cliff. The Independent focused on how the glass cliff is not a local, but global phenomena: “ *Subsequent research in an array of environments has demonstrated that this is not an isolated issue, nor is it unique to certain industries or geographical locations. It reveals that women in top leadership positions seem to be routinely handed inherently unsolvable problems….This creates a damaging, self-fulfilling prophecy that women are unsuitable for leadership positions. Not only does it knock the confidence of the woman in question, it also makes organisations wary of recruiting women to these positions.*” [5.5].

Forbes not only explains and expands on the glass cliff but encourage women to stand up against it and encourages companies to reevaluate their hiring practices: “ Instead of focusing on the fact that female leaders are being set up to fail, we should be looking for ways to fight back against it. Let’s encourage all companies to look into their unconscious bias and push for more women to take on C suite roles in those that are continuously successful” [5.6]. The glass cliff sparked discussion on the US television programme, The Daily Show (June 2019). The host, Trevor Noah interviewed IMF president Christine Legarde, and they both used the term “the glass cliff” to understand Legarde’s appointment (average viewing audience of 1.43 million people per episode) catalyzing further discussion (e.g. on CNN) of the scarcity of female leadership. A month later Legarde continued the theme in an interview with Quartz to highlight why women should be encouraged to take those opportunities as a means to empower their position. [5.7] The glass cliff concept was also discussed and used in the fictional TV show “Younger” (June 2019) as a theme for its entire season, to describe female characters being set up for failure in times of crisis whilst also proposing in the fictional setting the ways in which women might succeed in such positions (average viewership of over 1 million people) [5.8].

As a consequence, guides to surviving the glass cliff have emerged. For example, Fundera a US company specializing in loans for small businesses created a “What is the glass cliff: 7 ways female business leaders can avoid falling off” infographic; on the World Economic Forum web platform for the Middle East and North Africa, the CEO of Siemens Oman wrote a similarly which was then published on LinkedIn; Home Business highlighted their “Don’t Trip Over the Glass Cliff” for female entrepreneurs [5.9].

The glass cliff discourse has recently impacted conversations about corporate racism and ethnic minorities in leadership with coverage, for example, in Business Insider and Vox [5.10] magazines, and recent tweets from, for example, Michelle Lee editor-in-chief of Allure magazine (5.3M monthly readership) stating “ I’ve thought a lot about the glass cliff... keep in mind when you see POC (people of colour) in leadership positions, that they may face challenges their predecessors have not had” [5.10].

Informing National Clinical Guidelines

O’Mahen’s research [3.1, 3.2] on perinatal mental health problems (PMH-P) interventions directly informed the 2014 NICE Antenatal and Postnatal Mental Health Guidelines [5.1] in three ways:

• Overarching guidance that psychological treatment should be adapted for perinatal specific concerns and delivered by perinatal competent providers (p.378).

• Guidelines for using CBT specifically for PND (p. 649).

• Two new recommendations for perinatal facilitated self-help (p.378, 649).

The lead of the guideline development group confirmed that “ This [Exeter] research has made a significant contribution to improving mental health treatment and access to women with PMH problems. These new recommendations in the NICE guidelines would not have been possible without the work produced by Prof O’Mahen.” [5.4]

O’Mahen’s research also informed the later 2017 Welsh Matrix Guidelines [5.2] which focuses on the need for improved access to perinatal mental health (PMH) services in Wales. O’Mahen’s trials were two of three studies underpinning the “A” research quality recommendation for guided self-help for mild antenatal or postnatal depression and was the singular study supporting the recommendation of Cognitive Behavioural Therapy for antenatal depression [5.2].

Figure 1: A schematic to illustrate the process of impact generation

Influencing clinical standard-setting in PMH psychological treatment provision in primary and secondary care

O’Mahen’s research on psychological interventions adapted for PMH-P has shaped government policy and guidance and influenced the structure of psychological treatment provision in both primary and secondary mental health care. O’Mahen was one of a small number of specialists that contributed to the development of NICE’s Antenatal and Postnatal Mental Health Quality Standards [5.3]. In her expert role, O’Mahen drew on the 2014 NICE guidelines, as described above, to ensure that prompt access to perinatally adapted psychological interventions was included as one of six key targets that providers of PMH-P care should meet.

Both the quality care standards and 2014 NICE guidelines inform the pathways to mental health care for perinatal parents in the UK and the government has recognised this as a priority area. Faced with considerable national disparities in the provision of care to perinatal parents, the UK government invested £365 million in the 5 Year Forward View (2016) and £1,015 billion in the Long-Term Plan (2019) to ensure parents in the UK received NICE guideline-concordant care for PMHP. NHS England projects 66,000 perinatal women will access perinatal community mental health teams each year (25% of women with PMHP problems). In addition, Improving Access to Psychological Therapies (IAPT) aims to treat 87,750 (25%) of mothers and fathers with PMH problems per annum.

O’Mahen’s work also then contributed to a wide-scale national transformation in the provision of perinatal specific psychological treatment. From her work, 980 therapists and 2,100 perinatal practitioners (80% already established and 100% of new psychologists) [5.7, 5.9, 5.10] have been trained in delivering evidence based perinatal treatment including Exeter-developed psychological interventions [3.3, 3.4, 3.5, 3.6], which offer cost-effective treatment for the NHS, treating over an estimated 61,163 people.

Shaping Clinical Competences Frameworks

Exeter headed the development of the national psychological clinical standards of practice and co-wrote the Health Education England (HEE) perinatal psychological assessment and therapy competencies [5.5]. O’Mahen led on NHS England and IAPT funded (£50,000) awards to develop a national IAPT perinatal competency framework, and national perinatal practice guide for IAPT practitioners [5.6]. These frameworks draw directly on O’Mahen’s research specifying how to adapt the content and delivery of treatments for PMH problems (e.g., PND, anxiety). The frameworks support identifying staff competency and training needs and set a foundation on which to develop training curriculum content. The PMH training lead for London stated that “...Prof. O’Mahen’s research on interventions for perinatal depression highlight the specific content and delivery adaptations needed to ensure the effective provision of mental health treatments during the perinatal period. As such, her research has made a significant contribution to the competences and training underpinning the competent delivery of evidence based mental health treatment to perinatal mothers...”. [5.10]

Creating a national training program for all new UK perinatal psychologists

With colleagues from the University of Liverpool, IAPT, the British Psychological Association Perinatal Faculty and Exeter, O’Mahen led the development and implementation of national training programmes in primary and secondary care with content developed from her research. She has now trained a national multidisciplinary cohort of psychological practitioners, clinical psychologists, psychiatrists, midwives, and health visitors.

O’Mahen’s training for perinatal clinicians has included a HEE national training program for all new UK perinatal psychologists in the NHS England expanded perinatal community mental health teams, which she led on with staff at Exeter and colleagues from the University of Liverpool. The course is highly rated (mean=8/10) on developing perinatal-relevant skills. This program has been recommissioned for additional psychologists (n=140) in 2020/2021 and 2021/2022. Assuming a 20-year career course, this training will influence the care of up to 1,320,000 perinatal women.  " Prof. O’Mahen, ...has led on the delivery of the national training program for perinatal psychologists, [which was] based on evidence-based interventions, drawn from perinatal trials in the 2014 NICE Antenatal and Postnatal Guidelines, which included Prof. O’Mahen’s research.” [5.10]

O’Mahen developed and delivered perinatal-bespoke training for IAPT primary care mental health providers, drawing heavily on the facilitated self-help materials O’Mahen trialled with Netmums. [5.8] As a service, we have found that the adaptations we now make (after your training and booklets) have made a huge difference in the positive feedback we get from new mums and pregnant women… and have made a difference in their clinical improvement and continued positive mental health”. [5.7]

This training has been far reaching, including:

• 650 IAPT clinicians from 66 services (50% of all services nationally, including 33 perinatal leads from each of the 33 IAPT services in London, treating up to 1400 women/each over career) who cascade training to their service which “.. .has been very helpful for all the IAPT Services treating mothers with PMH problems and their children, especially as it can be catered to their needs and personal goals.” [5.9] Feedback from this highly rated training (mean=4/5) indicated clinician attendees are using the training and booklets with a positive impact on women.

• O’Mahen’s perinatal self-help materials have been downloaded over 2,491 times, 648 by IAPT/primary care therapists.

Nationally, over 60% of IAPT services have used the perinatal guided self-help materials or received training based on O’Mahen’s research, treating up to 3,800 women/year.

Informing the development and production of a successful online self-help programme and face-to-face treatments

The Head of Support at Netmums stated in 2020 [5.8]: “ We were pleased to work with Prof. O’Mahen to offer one of the first online CBT courses for postnatal depression, raising considerable awareness of postnatal depression and supporting women to overcome their symptoms. Since its inception, over 37,000 women have benefitted.”

Further expanding the reach of O’Mahen’s perinatal “Netmums” intervention, Exeter, with a grant from FutureLearn, developed an online training programme for the mCBT aimed at healthcare professionals. Over 237,537 people joined the 3-week course in 2019-202 This course has given me the tools I need to implement treatment with my patients.” This innovative form of teaching is meeting a clear gap in accessible, online training, providing clinicians with the skills to support perinatal women.”

International Reach

The impact of O’Mahen’s research has now had international reach. In recognition of the success of the Netmums course, it has been adapted in the United States, and Japan, where it is offered in two major area hospitals providing care for over 10,000 mothers in the Tokyo/Yokohama areas. Others have also referenced this course in their own development of postnatal online courses in Spain, the Netherlands, and Canada. [5.8] Further, all perinatal psychologists in Gothenberg, Sweden now offer the antenatal anxiety intervention O’Mahen and colleagues developed.

The resulting impact is O’Mahen’s PMH-P research and interventions continue to inform & shape clinical guidelines and practice, and provide affordable and accessible mental health care for women with PMH-P both in the UK and internationally.