A patient who changed my practice: The case for patient-based evidence versus trial-based evidence

A patient who has an unequivocal psychotic illness within the schizoaffective spectrum is described. Over the course of the past 10 years she has convinced me that her way of looking at her own illness, particularly her refusal to take medication, has merits that cannot be dismissed as the overwrought workings of a disturbed mind. Her experience has helped me to understand that it is still possible to be an advocate of evidence-based medicine and yet accommodate the wishes of patients in a way that sometimes elevates personal patient-based evidence above that of external criteria. ( Int J Psych Clin Pract 2000; 4: 253 - 255).

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), the Cochrane Library (1998, Issue 2), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. The Journal of Personality Disorders was hand searched, and contact was made with colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

The selection of trials, assessment of quality and data extraction was undertaken independently and in parallel by two reviewers. Where possible the data were entered into RevMan and an intention-to-treat analysis undertaken. Tests of heterogeneity were undertaken.

MAIN RESULTS

CMHT management may be associated with fewer deaths by suicide and in suspicious circumstances (OR 0.32 CI 0.09-1.12). It causes less people to be dissatisfied with their care (OR 0.34 CI 0.2-0.59) and to leave the studies early (OR 0.61 CI 0.45-0.83). No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment, although this was partly a consequence of poorly presented data.

REVIEWER'S CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

Intensive case management for psychotic patients with borderline intelligence. UK 700 Group

Patients with recurrent psychotic disorder and borderline learning disability who were randomly assigned intensive case management spent less than half the subsequent time in hospital than those who were assigned standard case management.

Prevalence and characteristics of patients with severe mental illness and borderline intellectual functioning. Report from the UK700 randomised controlled trial of case management

BACKGROUND

Low cognitive ability and developmental delays have been implicated in the causation of mental illness.

AIMS

To examine the prevalence, socio-demographic characteristics, psychopathology and social functioning profiles of people with low intelligence and recurrent psychotic illness.

METHOD

A multi-centre randomised controlled trial of case management provided the opportunity to explore associations between mental illness and borderline intellectual functioning (assessed using the National Adult Reading test).

RESULTS

Overall prevalence of borderline intelligence was 18%. Significant positive associations were shown with: being Black Caribbean; having a father who worked in a manual occupation; lower educational achievement; having had special education; longer course of illness. Those with borderline intelligence had greater disability and were more likely to suffer extrapyramidal side-effects and show evidence of negative symptoms. Educational achievement, history of special education and social class were the best socio-demographic predictors of intellectual level.

CONCLUSIONS

Many patients who attend generic psychiatric services have considerable intellectual deficits. This may lead to difficulties in other domains of adaptive functioning, and merits further investigation as well as clinical vigilance.

Intensive versus standard case management for severe psychotic illness: a randomised trial. UK 700 Group

BACKGROUND

Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased. Despite equivocal results, in the UK and Europe, this approach is becoming accepted policy. We assessed the effect of smaller case loads.

METHODS

We randomly assigned 708 psychotic patients in four centres standard case management (355 patients, case load 30-35 per case manager) or intensive case management (353 patients, case load 10-15 per case manager). We measured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients. Analysis was by intention to treat.

FINDINGS

There was no significant decline in overall hospital use among intensive-case-management patients (mean 73.5 vs 73.1 days in those who received standard care [SD 0.4, 95% CI -17.4 to 18.1]), nor were there any significant gains in clinical or social functioning. There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients.

INTERPRETATION

In well-coordinated mental-health services, a decline in case load alone does not improve outcome for these patients. Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation.

Long-term outcome of hypochondriacal personality disorder

Hypochondriacal personality disorder diagnosed according to the Personality Assessment Schedule, a structured clinical interview, was related to outcome after 2 years and 5 years in a randomized, controlled trial of treatment of generalized anxiety, panic, and dysthymic disorders. Seventeen individuals (9%) from a population of 181 patients had hypochondriacal personality disorder and they experienced a significantly worse outcome than other patients, including those with other personality disorders, in terms of symptomatic change and health service utilization. This lack of improvement was associated with persistent somatization in hypochondriacal personality disorder. The results give further support to the belief that hypochondriacal personality disorder is a valid clinical diagnosis that has important clinical correlates, but further work is needed to establish the extent of its overlap with hypochondriasis as a mental state disorder.

Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm

BACKGROUND

The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy.

METHODS

Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N = 18) or treatment as usual (TAU N = 16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined.

RESULTS

Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/month MACT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT (P = 0.22).

CONCLUSIONS

Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.

Systematic review of the outcome of anxiety and depressive disorders

BACKGROUND

Although there have been many changes in the diagnosis of anxiety and depressive disorders in the past 20 years there have been few comparative enquiries into the clinical outcome of greater diagnostic categories. We therefore compared the outcome of all studies which compared the outcome of specific anxiety and depressive disorders using the standard procedures of systematic review.

METHOD

A Medline search was carried out of all studies comparing the outcome of anxiety and depressive disorders or mixed anxiety--depressive disorders in which information was available separately for each disorder.

RESULTS

Eight studies satisfied the search criteria (all involving a period of observation of two years or greater); only one of these included randomisation of treatment and comparison between specific anxiety disorder outcome. There was a somewhat better outcome in patients with depressive disorders compared with anxiety ones, and strong evidence that both anxiety and depressive disorders singly had better outcomes than comorbid mixed disorders.

CONCLUSION

Comorbid anxiety--depressive disorders have a poor outcome compared with single anxiety and depressive disorders, and there is some evidence that anxiety disorders have a worse outcome than depressive ones.

Recovery of positive future thinking within a high-risk parasuicide group: results from a pilot randomized controlled trial

OBJECTIVES

The research examined: (i) whether high risk parasuicide patients showed a deficit in positive future thinking but no increase in negative future thinking; and (ii) whether such a deficit could be remedied by a brief, manual-assisted psychological intervention (manual assisted cognitive-behaviour therapy; MACT).

DESIGN

A cross-sectional, mixed model design was used to assess differences between a sample of high risk parasuicide patients and matched controls on future thinking. A longitudinal mixed model design was used to assess changes in future thinking in the different groups over time.

METHODS

Parasuicide patients with a history of previous suicidal behaviour and personality disturbance were compared with a matched group of community controls on an adapted fluency measure of future thinking, which measured both quantitative and qualitative aspects of anticipated experiences. Patients were then randomly allocated to either the specific intervention (MACT) or treatment as usual (TAU) and assessed again at 6 month follow-up.

RESULTS

Parasuicide patients showed reduced positive future thinking but no increased negative future thinking. Patients who received MACT showed a significant improvement in positive future thinking over the follow-up period whereas the TAU group showed no such improvement. However, interpretation of this finding was made more difficult by the control group also showing a significant improvement in positive future thinking.

CONCLUSION

The results confirm that parasuicide patients exhibit a relative deficit in positive future thinking and suggest that this lack of positive future thinking may be remedied, at least partly, by a brief intervention.

Prediction of outcome in neurotic disorder: a 5-year prospective study

BACKGROUND

There have been no previous studies of the outcome of different neurotic disorders in which a prospective group with original randomization to treatment have been followed up over a long period. Such studies are important in identifying the factors associated with good and poor outcome.

METHODS

A 5-year follow-up assessment was made of a cohort of 210 psychiatric out-patients seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74) or dysthymic disorder (65) and randomized to drug treatment, cognitive and behaviour therapy, and self-help. A total of 182 of the patients (87%) were assessed after 5 years by examination of hospital and GP records using a standardized procedure and outcome determined with a four-point outcome scale.

RESULTS

One hundred and seven (60%) of the patients had a favourable outcome but the remainder continued to be handicapped either intermittently or continuously throughout the 5-year period. Analysis of the value of initial data in predicting outcome using polychotomous step-wise logistic regression revealed that five variables were significant predictors of poor prognosis: older age; recurrent episodes; the presence of personality disorder at entry; general neurotic syndrome at entry; and symptom severity after 10 weeks. The initial DSM diagnosis and original treatment given, together with ten other variables, were of no predictive value.

CONCLUSIONS

The long-term outcome of neurotic disorder is better predicted by age, personality and recency of onset than by other clinical variables with the exception of initial response to treatment.

Randomised controlled trial of two models of care for discharged psychiatric patients

OBJECTIVE

To compare the clinical outcome and costs of care of psychiatric patients allocated to community multidisciplinary teams or to hospital based care programmes after discharge from inpatient care.

DESIGN

Randomised controlled trial.

SETTING

Inner London (Paddington and North Kensington) and outer London (Brent) psychiatric services.

SUBJECTS

155 patients with severe mental illness with a previous admission within the past 2 years.

MAIN OUTCOME MEASURES

Ratings of clinical psychopathology, depression, anxiety, and social functioning; comprehensive costs of health care.

RESULTS

Clinical outcomes were available for 133 patients and cost data for 144 patients after 1 year. The clinical outcomes of the two models of care were essentially similar, but admission to hospital was more likely in the hospital based care group and the costs of health care were 14% greater per patient than in the community group. This difference, however, was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London. This was explained largely by greater inpatient care for outer London patients (58 median bed days v 18 for inner London patients), more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study.

CONCLUSION

Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital. When psychiatric bed requirements are insufficient for a population, however, neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes, with disintegration and discontinuity of psychiatric services leading to escalating costs.

Heuristic models of comorbidity of axis I and axis II disorders

The mechanisms responsible for the co-occurrence of personality disorders with Axis I disorders are not well understood. We propose a number of models that include various relationships at the etiological, pathophysiological, and observable clinical levels between personality disorders and Axis I disorders. It is recommended that such models be subjected to empirical tests to assess their validity.

Extent of comorbidity between mental state and personality disorders

Comorbidity between major psychiatric disorders (Axis I) and personality disorders (Axis II) is widespread, often extremely strong, and invariably confusing. The strongest associations are found between substance use and the cluster B (flamboyant) personality disorders, anxiety disorders and the anxious/fearful personality group (cluster C), and between somatisation and both cluster B and C disorders. The significance of these associations is far from clear, and almost certainly include more than one type of relationship. Empirical studies of patients with and without Axis I and II comorbidity show that the presence of a personality disorder can affect the outcome of treatment, both positively and negatively, in a way that currently appears unpredictable. One useful way of interpreting this comorbidity is by postulating personality dispositions that make some people prone to certain mental state disorders.

Diagnosis of 'ME', which makes an external attribution for fatigue

To the Editor: The paper by Chalder et al. (26, 791–800) in a cross-sectional study concludes that the diagnosis of ‘ME’, which makes an external attribution for fatigue, ‘seems to protect against psychological distress but not against disability’. We should like to offer strong support for this conclusion from the prospective data of a patient involved in a 12-year study of the outcome of neurotic disorder.