Client Socio-Demographic and Service Receipt Inventory--European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

Supported employment: cost-effectiveness across six European sites

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support (IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n=312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment.

Treating alcoholism reduces financial burden on care-givers and increases quality-adjusted life years

AIMS

The study assessed the alcoholism-related financial burden borne by informal care-givers and relatives of German alcoholic patients.

DESIGN

By using an exploratory approach, care-giver burden was assessed both prior to and 12 months after detoxification and withdrawal. Quality-of-life data for care-givers collected during follow-up were used to calculate the number of quality-adjusted life years (QALYs) gained by alcoholics' family members while their relatives are undergoing treatment.

PARTICIPANTS

Forty-eight informal care-givers and relatives of alcoholic patients.

SETTING

In-patient and out-patient departments of three psychiatric university hospitals in Germany.

MEASUREMENTS

Expenditures of families related directly to the addiction disorder of alcoholic patients, quality of life of care-givers, relapses of patients.

FINDINGS

Families' expenditures related directly to their addicted member's alcoholism decreased from an average of €676.44 per month (or 20.2% of the total pre-tax family income) at baseline to an average of €145.40 per month at 12 months after the beginning of treatment. The average time spent caring for the affected family member was reduced from 32.3 hours per month to 8.2 hours per month (P = 0.0109), and quality-of-life total scores increased from 60.6 to 68.0. The total gain in QALYs for family members was 0.108. When weighed against the average cost of the alcoholism treatment, the cost of one QALY for care-giving family members was €20,398 on average.

CONCLUSIONS

Among the families of German alcoholics who receive detoxification, there is a substantial reduction in family expenditures, time spent caring and an increase in quality of life at 1 year. These are important but often neglected additional measures of the burden on family members and also treatment benefits.

INTERBED: internet-based guided self-help for overweight and obese patients with full or subsyndromal binge eating disorder. A multicenter randomized controlled trial

Background

Binge eating disorder (BED) is a prevalent clinical eating disorder associated with increased psychopathology, psychiatric comorbidity, overweight and obesity, and increased health care costs. Since its inclusion in the DSM-IV, a few randomized controlled trials (RCTs) have suggested efficacy of book-based self-help interventions in the treatment of this disorder. However, evidence from larger RCTs is needed. Delivery of self-help through new technologies such as the internet should be investigated in particular, as these approaches have the potential to be more interactive and thus more attractive to patients than book-based approaches. This study will evaluate the efficacy of an internet-based guided self-help program (GSH-I) and cognitive-behavioral therapy (CBT), which has been proven in several studies to be the gold standard treatment for BED, in a prospective multicenter randomized trial.

Methods

The study assumes the noninferiority of GSH-I compared to CBT. Both treatments lasted 4 months, and maintenance of outcome will be assessed 6 and 18 months after the end of treatment. A total of 175 patients with BED and a body mass index between 27 and 40 kg/m² were randomized at 7 centers in Germany and Switzerland. A 20% attrition rate was assumed. As in most BED treatment trials, the difference in the number of binge eating days over the past 28 days is the primary outcome variable. Secondary outcome measures include the specific eating disorder psychopathology, general psychopathology, body weight, quality of life, and self-esteem. Predictors and moderators of treatment outcome will be determined, and the cost-effectiveness of both treatment conditions will be evaluated.

Results

The methodology for the INTERBED study has been detailed.

Conclusions

Although there is evidence that CBT is the first-line treatment for BED, it is not widely available. As BED is still a recent diagnostic category, many cases likely remain undiagnosed, and a large number of patients either receive delayed treatment or never get adequate treatment. A multicenter efficacy trial will give insight into the efficacy of a new internet-based guided self-help program and will allow a direct comparison to the evidence-based gold standard treatment of CBT in Germany.

Trial Registration

Current Controlled Trials ISRCTN40484777

German Clinical Trial Register DRKS00000409

Effectiveness of antipsychotic maintenance therapy with quetiapine in comparison with risperidone and olanzapine in routine schizophrenia treatment: results of a prospective observational trial

Objective of this observational trial is to examine the effects of quetiapine in comparison with olanzapine and risperidone on clinical outcomes and quality of life in patients with schizophrenia and schizoaffective disorder in routine care. 374 adult persons with schizophrenia or schizoaffective disorder prescribed antipsychotic maintenance therapy with quetiapine, olanzapine, or risperidone at discharge from inpatient treatment were included. Clinical and psychosocial outcomes were assessed before discharge and at 6, 12, 18, and 24 months. Statistical analyses were conducted by mixed-effects regression models for longitudinal data. The propensity score method was used to control for selection bias. Patients discharged on olanzapine had significantly lower hospital readmissions than those receiving quetiapine or risperidone. The average chlorpromazine equivalent dose of quetiapine was higher than in patients treated with olanzapine or risperidone. No further significant differences between treatment groups were found. Quetiapine and risperidone are less effective in preventing the need for psychiatric inpatient care than olanzapine, and higher chlorpromazine equivalent doses of quetiapine are needed to obtain clinical effects similar to those of olanzapine and risperidone.

Nature and determinants of out-of-pocket health expenditure among older people in a rural Indian community

BACKGROUND

Increasing out-of-pocket health expenditure among older people worsens the inequitable access to essential health services in low and middle-income countries (LMIC). We investigated various socioeconomic and health factors associated with out-of-pocket and catastrophic health expenditures among rural older people in India.

METHODS

We recruited 1,000 participants aged above 65 years from Kaniyambadi block, Vellore, India. We assessed their out-of-pocket health expenditure, health service utilization, socioeconomic profiles, disability, cognition, and health status by standard instruments. We employed appropriate multivariate statistics evaluating these determinants.

RESULTS

Male gender, poor sanitation, diabetes, tuberculosis, malaria, respiratory ailments, gastrointestinal diseases, dementia, depression, and disability were associated with higher out-of-pocket expenditures. Illiteracy, tuberculosis, diabetes, and dementia increased the risk for catastrophic health expenditures, while pension schemes protected against it. Income inequalities were associated with inequities on education, disease prevalence, and access to safe water, sanitation, and nutrition.

CONCLUSIONS

Interactions between determinants of out-of-pocket health expenditure, economic inequality, and inequities on essential health care delivery to older people are complex. We highlight the need for equitable health services and policies, focusing on both medical and social determinants.

Economic evaluation of a task-shifting intervention for common mental disorders in India

OBJECTIVE

To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary-care settings in Goa, India.

METHODS

Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy and/or antidepressants by lay health workers. Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months.

FINDINGS

Complete data, from all three follow-ups, were collected from 1243 (75.4%) and 938 (81.7%) of the subjects enrolled in the study facilities from the public and private sectors, respectively. Within the public facilities, subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm. Time costs were also significantly lower in the intervention arm than in the control arm, whereas health system costs in the two arms were similar. Within the private facilities, however, the effectiveness and costs recorded in the two arms were similar.

CONCLUSION

Within public primary-care facilities in Goa, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving.

Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

Background

The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.

Methods

Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.

Results

The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.

Conclusions

Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring

BACKGROUND

The high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples. The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients' perceived coercion and to increase patient satisfaction, their quality of life and empowerment.

METHODS/DESIGN

This paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study. In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge.

DISCUSSION

Innovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.

Validation of the Integrative Hope Scale in people with psychosis

Hope is an important variable in mental health, particularly in the emergent field of research focused on recovery and well-being. This study validates the "Integrative Hope Scale" (IHS) for use in people with severe mental illness. Two hundred participants diagnosed with schizophrenia or schizoaffective disorder were assessed using the IHS, the Centre for Epidemiological Studies Depression Scale, and the Positive and Negative Syndrome Scale. Sixty participants were re-assessed after 14 days to establish re-test reliability. Confirmatory factor analysis was carried out; correlations between the scales and kappa coefficients were used to establish validity and reliability. The factor analysis confirmed a four-factor solution with excellent model fit, after minor modifications to the initial model. Discriminant validity and internal consistency were excellent. Test-retest reliability was good except for one item. This study suggests the scale to be a valid, reliable and feasible tool for the assessment of hope in people with severe mental illness. It provides a sound basis for future research on hope in mental health. For use in people with psychosis, we suggest some minor modifications to the scale.

The Depression in Visual Impairment Trial (DEPVIT): trial design and protocol

BACKGROUND

The prevalence of depression in people with a visual disability is high but screening for depression and referral for treatment is not yet an integral part of visual rehabilitation service provision. One reason for this may be that there is no good evidence about the effectiveness of treatments in this patient group. This study is the first to evaluate the effect of depression treatments on people with a visual impairment and co morbid depression.

METHODS /DESIGN

The study is an exploratory, multicentre, individually randomised waiting list controlled trial. Participants will be randomised to receive Problem Solving Therapy (PST), a 'referral to the GP' requesting treatment according to the NICE's 'stepped care' recommendations or the waiting list arm of the trial. The primary outcome measure is change (from randomisation) in depressive symptoms as measured by the Beck's Depression Inventory (BDI-II) at 6 months. Secondary outcomes include change in depressive symptoms at 3 months, change in visual function as measured with the near vision subscale of the VFQ-48 and 7 item NEI-VFQ at 3 and 6 months, change in generic health related quality of life (EQ5D), the costs associated with PST, estimates of incremental cost effectiveness, and recruitment rate estimation.

DISCUSSION

Depression is prevalent in people with disabling visual impairment. This exploratory study will establish depression screening and referral for treatment in visual rehabilitation clinics in the UK. It will be the first to explore the efficacy of PST and the effectiveness of NICE's 'stepped care' approach to the treatment of depression in people with a visual impairment.

TRIAL REGISTRATION

ISRCTN46824140.

Development of a database of instruments for resource-use measurement: purpose, feasibility, and design

BACKGROUND

Health economists frequently rely on methods based on patient recall to estimate resource utilization. Access to questionnaires and diaries, however, is often limited. This study examined the feasibility of establishing an open-access Database of Instruments for Resource-Use Measurement, identified relevant fields for data extraction, and outlined its design.

METHODS

An electronic survey was sent to authors of full UK economic evaluations listed in the National Health Service Economic Evaluation Database (2008-2010), authors of monographs of Health Technology Assessments (1998-2010), and subscribers to the JISCMail health economics e-mailing list. The survey included questions on piloting, validation, recall period, and data capture method. Responses were analyzed and data extracted to generate relevant fields for the database.

RESULTS

A total of 143 responses to the survey provided data on 54 resource-use instruments for inclusion in the database. All were reliant on patient or carer recall, and a majority (47) were questionnaires. Thirty-seven were designed for self-completion by the patient, carer, or guardian, and the remainder were designed for completion by researchers or health care professionals while interviewing patients. Methods of development were diverse, particularly in areas such as the planning of resource itemization (evident in 25 instruments), piloting (25), and validation (29).

CONCLUSION

On the basis of the present analysis, we developed a Web-enabled Database of Instruments for Resource-Use Measurement, accessible via www.DIRUM.org. This database may serve as a practical resource for health economists, as well as a means to facilitate further research in the area of resource-use data collection.

Strain and its correlates among carers of people with dementia in low-income and middle-income countries. A 10/66 Dementia Research Group population-based survey

OBJECTIVES

In a multi-site population-based study in several middle-income countries, we aimed to investigate relative contributions of care arrangements and characteristics of carers and care recipients to strain among carers of people with dementia. Based on previous research, hypotheses focused on carer sex, care inputs, behavioural and psychological symptoms (BPSD) and socioeconomic status, together with potential buffering effects of informal support and employing paid carers.

METHODS

In population-based catchment area surveys in 11 sites in Latin America, India and China, we analysed data collected from people with dementia and care needs, and their carers. Carer strain was assessed with the Zarit Burden Interview.

RESULTS

With 673 care recipient/carer dyads interviewed (99% of those eligible), mean Zarit Burden Interview scores ranged between 17.1 and 27.9 by site. Women carers reported more strain than men. The most substantial correlates of carer strain were primary stressors BPSD, dementia severity, needs for care and time spent caring. Socioeconomic status was not associated with carer strain. Those cutting back on work experienced higher strain. There was tentative evidence for a protective effect of having additional informal or paid support.

CONCLUSIONS

Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training. That giving up work to care was prevalent and associated with substantial increased strain emphasizes the economic impact of caring on the household. Carer benefits, disability benefits for people with dementia and respite care should all be considered.

Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment

OBJECTIVE

Evaluating the effects of different types of psychotropic polypharmacy on clinical outcomes and quality of life (QOL) in 374 patients with schizophrenia and schizoaffective disorder in routine care.

METHOD

Psychotropic regimen, clinical outcomes, and QOL were assessed before discharge and after 6, 12, 18, and 24 months. Data were analyzed by mixed-effects regression models for longitudinal data controlling for selection bias by means of propensity scores.

RESULTS

At baseline 22% of participants received antipsychotic monotherapy (APM) (quetiapine, olanzapine, or risperidone), 20% more than one antipsychotic drug, 16% received antipsychotics combined with antidepressants, 16% antipsychotics plus benzodiazepines, 11.5% had antipsychotics and mood stabilizers, and 16% psychotropic drugs from three or more subclasses. Patients receiving APM had better clinical characteristics and QOL at baseline. Patients receiving i) antipsychotics plus benzodiazepines or ii) antipsychotics plus drugs from at least two additional psychotropic drug categories improved less than patients with APM.

CONCLUSION

Combinations of antipsychotics with other psychotropic drugs seem to be effective in special indications. Nevertheless, combinations with benzodiazepines and with compounds from multiple drug classes should be critically reviewed. It is unclear whether poorer outcomes in patients with such treatment are its result or its cause.

Effectively working on rehabilitation goals: 24-month outcome of a randomized controlled trial of the Boston psychiatric rehabilitation approach

OBJECTIVE

To investigate the effect of the Boston Psychiatric Rehabilitation (PR) Approach on attainment of personal rehabilitation goals, social functioning, empowerment, needs for care, and quality of life in people with severe mental illness (SMI) in the Netherlands.

METHOD

A 24-month, multicentre, randomized controlled trial was used to compare the results of PR to care as usual (CAU). Patients with SMI were randomly assigned by a central randomization centre to PR (n = 80) or CAU (n = 76). The primary outcome of goal attainment was assessed by independent raters blind to treatment allocation. Measures for secondary outcomes were change in work situation and independent living, the Personal Empowerment Scale, the Camberwell Assessment of Needs, and the World Health Organization Quality of Life assessment. Effects were tested at 12 and 24 months. Data were analyzed according to intention to treat. Covariates were psychiatric centre, psychopathology, number of care contacts, and educational level of the professionals involved.

RESULTS

The rate of goal attainment was substantially higher in PR at 24 months (adjusted risk difference: 21%, 95% CI 4% to 38%; number needed to treat [NNT] = 5). The approach was also more effective in the area of societal participation (PR: 21% adjusted increase, CAU: 0% adjusted increase; NNT = 5) but not in the other secondary outcome measures.

CONCLUSIONS

The results suggest that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.

Interpersonal community psychiatric treatment for non-psychotic chronic patients and nurses in outpatient mental health care: a controlled pilot study on feasibility and effects

BACKGROUND

In psychiatric care professionals perceive some patients as 'difficult', especially patients with long-term non-psychotic disorders. For these patients few evidence-based treatments exist. An intervention program, Interpersonal Community Psychiatric Treatment (ICPT), was developed by the authors. It was evaluated with the aim to increase effective behaviours by both patients and community psychiatric nurses (CPNs).

OBJECTIVE

To assess the feasibility and effectiveness of an intervention program for use by CPNs in the care of 'difficult' patients with non-psychotic chronic disorders, in a controlled pilot study.

DESIGN

A mixed-methods quasi-experimental study using process and outcome measures across several dimensions. Measurements took place at 0, 3, and 6 months.

SETTINGS

Three community mental health centres in the centre of The Netherlands.

PARTICIPANTS

14 CPNs and 36 long-term non-psychotic patients who were perceived as 'difficult' were selected. Patients were offered either ICPT (20) or care as usual (16). All patients and CPNs could be followed up at all measurements.

METHODS

Quantitative data included type and severity of psychiatric disorder, psychosocial functioning, needs for care, quality of life and social participation. Also, service use, satisfaction with care, and quality of the therapeutic alliance were measured. Qualitative interviews were conducted with all CPNs and patients in the experimental group.

RESULTS

ICPT was found feasible by both CPNs and patients. Both the experimental and control condition showed improvement on a number of outcomes. ICPT, however, resulted in significantly better results in some areas. Patients' social network size increased and their care utilization decreased. Also, the quality of the working alliance increased and perceived patient difficulty decreased, both as scored by professionals.

CONCLUSIONS

ICPT is one of very few intervention programs aimed at 'difficult' non-psychotic chronic patients. In this pilot study was found that it can be successfully carried out by CPNs, is generally experienced as acceptable and useful by patients and CPNs alike, and results in some significantly better effects on both process and outcome measures. In the main study, some alterations will be made to the instruction manual and training program. Also, the diagnostic interview may be briefer, and the characteristics and treatment integrity of CPNs will be included in measurements. Further controlled and randomized research is needed to test the effectiveness of the program in a larger group of patients.

Motivational intervention to reduce cannabis use in young people with psychosis: a randomized controlled trial

BACKGROUND

Cannabis use has a negative impact on psychosis. Studies are needed to explore the efficacy of psychological interventions to reduce cannabis use in psychosis. Our aim is to study the efficacy of a specific motivational intervention on young cannabis users suffering from psychosis.

METHODS

Participants (aged less than 35 years) were randomly assigned to treatment as usual (TAU) alone, or treatment as usual plus motivational intervention (MI + TAU). TAU was comprehensive and included case management, early intervention and mobile team when needed. Assessments were completed at baseline and at 3, 6 and 12 months follow-up.

RESULTS

Sixty-two participants (32 TAU and 30 MI + TAU) were included in the study. Cannabis use decreased in both groups at follow-up. Participants who received MI in addition to TAU displayed both a greater reduction in number of joints smoked per week and greater confidence to change cannabis use at 3 and 6 months follow-up, but differences between groups were nonsignificant at 12 months.

CONCLUSIONS

MI is well accepted by patients suffering from psychosis and has a short-term impact on cannabis use when added to standard care. However, the differential effect was not maintained at 1-year follow-up. MI appears to be a useful active component to reduce cannabis use which should be integrated in routine clinical practice.

The serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial

BACKGROUND

The serious mental illness Health Improvement Profile [HIP] is a brief pragmatic tool, which enables mental health nurses to work together with patients to screen physical health and take evidence-based action when variables are identified to be at risk. Piloting has demonstrated clinical utility and acceptability.

METHODS/DESIGN

A single blind parallel group cluster randomised controlled trial with secondary economic analysis and process observation. Unit of randomisation: mental health nurses [MHNs] working in adult community mental health teams across two NHS Trusts.

SUBJECTS

Patients over 18 years with a diagnosis of schizophrenia, schizoaffective or bipolar disorder on the caseload of participating MHNs.

PRIMARY OBJECTIVE

To determine the effects of the HIP programme on patients' physical wellbeing assessed by the physical component score of the Medical Outcome Study (MOS) 36 Item Short Form Health Survey version 2 [SF-36v2].

SECONDARY OBJECTIVES

To determine the effects of the HIP programme on: cost effectiveness, mental wellbeing, cardiovascular risk, physical health care attitudes and knowledge of MHNs and to determine the acceptability of the HIP Programme in the NHS. Consented nurses (and patients) will be randomised to receive the HIP Programme or treatment as usual. Outcomes will be measured at baseline and 12 months with a process observation after 12 months to include evaluation of patients' and professionals' experience and observation of any effect on care plans and primary-secondary care interface communication. Outcomes will be analysed on an intention-to-treat (ITT) basis.

DISCUSSION

The results of the trial and process observation will provide information about the effectiveness of the HIP Programme in supporting MHNs to address physical comorbidity in serious mental illness. Given the current unacceptable prevalence of physical comorbidity and mortality in the serious mental illness population, it is hoped the HIP trial will provide a timely contribution to evidence on organisation and delivery of care for patients, clinicians and policy makers.

TRIAL REGISTRATION

ISRCTN

ISRCTN41137900.

Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria

BACKGROUND

To describe patterns of recent health service utilisation, and consequent out-of-pocket expenses among older people in countries with low and middle incomes, and to assess the equity with which services are accessed and delivered.

METHODS

17,944 people aged 65 years and over were assessed in one-phase population-based cross-sectional surveys in geographically-defined catchment areas in nine countries - urban and rural sites in China, India, Mexico and Peru, urban sites in Cuba, Dominican Republic, Puerto Rico and Venezuela, and a rural site in Nigeria. The main outcome was use of community health care services in the past 3 months. Independent associations were estimated with indicators of need (dementia, depression, physical impairments), predisposing factors (age, sex, and education), and enabling factors (household assets, pension receipt and health insurance) using Poisson regression to generate prevalence ratios and fixed effects meta-analysis to combine them.

RESULTS

The proportion using healthcare services varied from 6% to 82% among sites. Number of physical impairments (pooled prevalence ratio 1.37, 95% CI 1.26-1.49) and ICD-10 depressive episode (pooled PR 1.21, 95% CI 1.07-1.38) were associated with service use, but dementia was inversely associated (pooled PR 0.93, 95% CI 0.90-0.97). Other correlates were female sex, higher education, more household assets, receiving a pension, and health insurance. Standardisation for age, sex, physical impairments, depression and dementia did not explain variation in service use. There was a strong borderline significant ecological correlation between the proportion of consultations requiring out-of-pocket costs and the prevalence of health service use (r = -0.50, p = 0.09).

CONCLUSIONS

While there was little evidence of ageism, inequity was apparent in the independent enabling effects of education and health insurance cover, the latter particularly in sites where out-of-pocket expenses were common, and private health insurance an important component of healthcare financing. Variation in service use among sites was most plausibly accounted for by stark differences in the extent of out-of-pocket expenses, and the ability of older people and their families to afford them. Health systems that finance medical services through out-of-pocket payments risk excluding the poorest older people, those without a secure regular income, and the uninsured.

Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial

AIMS

Attempts to reduce high utilisation of mental health inpatient care by targeting the critical time of hospital discharge are rare. In this study, we test the effect of a needs-oriented discharge planning intervention on number and duration of psychiatric inpatient treatment episodes (primary), as well as on outpatient service use, needs, psychopathology, depression and quality of life (secondary).

METHODS

Four hundred and ninety-one adults with a defined high utilisation of mental health care gave informed consent to participate in a multicentre RCT carried out at five psychiatric hospitals in Germany (Düsseldorf, Greifswald, Regensburg, Ravensburg and Günzburg). Subjects allocated to the intervention group were offered a manualised needs-led discharge planning and monitoring intervention with two intertwined sessions administered at hospital discharge and 3 months thereafter. Outcomes were assessed at four measurement points during a period of 18 months following discharge.

RESULTS

Intention-to-treat analyses showed no effect of the intervention on primary or secondary outcomes.

CONCLUSIONS

Process evaluation pending, the intervention cannot be recommended for implementation in routine care. Other approaches, e.g. team-based community care, might be more beneficial for people with persistent and severe mental illness.

Recruitment into a guided internet based CBT (iCBT) intervention for depression: lesson learnt from the failure of a prevalence recruitment strategy

INTRODUCTION

Internet based Cognitive Behavioural Therapy (iCBT) represents a significant development in the way psychological interventions are delivered. Studies tend to recruit via common media channels leading to criticisms of biased sample sizes and limited generalisability to primary care settings.

AIM

To evaluate the use of a prevalence recruitment strategy within primary care to recruit into an RCT examining a free to use iCBT intervention.

METHODS

Fully randomised controlled trial (RCT), utilising a prevalence based recruitment strategy, comparing the iCBT intervention with telephone support provided by NHS Direct Health Advisors with treatment-as-usual (TAU) control.

RESULTS

Recruitment rates were low with only 7 participants recruited over 8 months. Overall only 14% of expected study invitations were sent, with only 1% undertaking the consent and initial screening process.

DISCUSSION

Key differences with successful prevalence recruitment strategies highlight four main issues to consider when recruiting participants from primary care into iCBT studies--lack of equipoise, a need for an assertive approach, coding of depression in GP databases and help seeking behaviour in depression which can all act as potential contributors to failure to recruit. However other non-primary care recruitment methods, such as the use of media channels, which are already shown to be effective in non-primary care settings should be considered if these methods more accurately target the population who would be willing to adopt iCBT more generally.

Mental disorder in Polish families: is diagnosis a predictor of caregiver's burden?

OBJECTIVE

To test whether a caregiver's burden is associated with the patient's psychiatric diagnosis and to find other predictors of family burden; to provide Polish data on the issue to international literature.

METHOD

Of 377 eligible subjects, 141 were interviewed on admission to the mental hospital using Brief Psychiatric Rating Scale, Manchester Short Assessment of Quality of Life, Groningen Social Disability Schedule and Client's Sociodemographic and Clinical History Inventory. Their caregivers completed the Involvement Evaluation Questionnaire (IEQ). Subjects were grouped according to ICD-10 diagnoses: schizophrenia (n = 55), depression (n = 61), and anxiety and personality disorders (n = 25). Highly aggressive, suicidal and somatically unstable patients were excluded along with patients below 18 and over 65 years. Statistics included multiple regression analysis, ANOVA, Kruskal-Wallis and chi-square tests.

RESULTS

Diagnostic groups differed with respect to sociodemographics, psychopathology and quality of life, but not with respect to mean level of social functioning. Despite between-group differences, the caregiver's burden did not differ according to the diagnostic group. Of the four dimensions of burden, "worrying" and "urging" scored the highest. Majority of caregivers worried about their relative's general health (82%), future (74%) and financial status (66%). Caregivers' characteristics and not patients' explained the largest proportion of the family burden variance (almost 23% for IEQ Tension). Higher burden seemed to be associated with the carer's age, being a parent and number of hours spent weekly on caring for the ill relative. Lower burden was associated with the carers' subjective feelings of being able to cope with problems and to pursue their own activities. Longer history of patient's illness led to higher IEQ Tension. Polish caregivers were affected by their role in the same way as their counterparts abroad, but more of them were worried.

CONCLUSIONS

The caregiver's burden seems to be independent of the patient's diagnosis, but other factors contribute to the perceived burden, many of which are on the caregiver's part. In Poland, the overall family burden may be attributed mostly to worrying about a mentally ill relative and his future. All caregivers may benefit from psychoeducation and family interventions usually planned for those caring for relatives with schizophrenia.

Effect of medication-related factors on adherence in people with schizophrenia: A European multi-centre study

Aim– To investigate the relation between medication-related factors and adherence in people with schizophrenia in outpatient treatment.Methods– The sample comprised 409 outpatients (ICD-10 diagnosis of schizophrenia) with clinician-rated instability in four European cities (Amsterdam, The Netherlands; Verona, Italy; Leipzig, Germany; London, Great Britain). Adherence was assessed using theMedication Adherence Questionnaire(patient perspective), and theClinician Rating Scale(clinician perspective). Examined medication-related factors were type (atypical vs. typical), application (oral vs. depot), daily dose frequency of antipsychotic medication (Medication History Scale), number of side effects (Liverpool University Neuroleptic Side Effect Rating Scale), and patient attitudes toward medication (Drug Attitude Inventory). Multiple regression analysis was used to identify predictors of adherence by medication-related factors.Results– Adherence, as rated by patient and clinician, was predicted by patient attitude towards medication, but was unrelated to type of drug, formulation or side effects of antipsychotic medication. A high daily dose frequency was associated with better adherence, but only when rated by the patient.Conclusions– In order to improve adherence there is a need to seriously consider and attempt to improve patient attitude toward medication. However, type of antipsychotic and other medication-related factors may not be as closely related to adherence as it has often been suggested.

Declaration of Interest:The study was funded by a grant from the Quality of Life and Management of Living Resources Program of the European Union (QLG4-CT-2001–01734). JM, AS, CB, MK, CB, LB, and BP declare that they have not received any form of financing including pharmaceutical company support or any honoraria for consultancies or interventions during the last two years. DR has received honoraria from Eli Lilly, Janssen Cilag and Astra Zeneca for consultancy work, and Anita Patel has received research consultancy funding from Servier. TB reports research funding to the department from Astra Zeneca, GlaxoSmithKline and Affectis for clinical trials and investigator-initiated trials; the department has also received funds to a minor extent for symposia and in-house training from Astra Zeneca, Bristol-Myers Squibb, Eisai, Janssen Cilag, Lilly Germany, Lundbeck, Novartis, Pfizer, Servier, and Wyeth. All authors declare that they have no other involvements that might be considered a conflict of interest in connection with this article.

The stigma of mental health problems and other barriers to care in the UK Armed Forces

Background

As with the general population, a proportion of military personnel with mental health problems do not seek help. As the military is a profession at high risk of occupational psychiatric injury, understanding barriers to help-seeking is a priority.

Method

Participants were drawn from a large UK military health study. Participants undertook a telephone interview including the Patient Health Questionnaire (PHQ); a short measure of PTSD (Primary Care PTSD, PC-PTSD); a series of questions about service utilisation; and barriers to care. The response rate was 76% (821 participants).

Results

The most common barriers to care reported are those relating to the anticipated public stigma associated with consulting for a mental health problem. In addition, participants reported barriers in the practicalities of consulting such as scheduling an appointment and having time off for treatment. Barriers to care did not appear to be diminished after people leave the Armed Forces. Veterans report additional barriers to care of not knowing where to find help and a concern that their employer would blame them for their problems. Those with mental health problems, such as PTSD, report significantly more barriers to care than those who do not have a diagnosis of a mental disorder.

Conclusions

Despite recent efforts to de-stigmatise mental disorders in the military, anticipated stigma and practical barriers to consulting stand in the way of access to care for some Service personnel. Further interventions to reduce stigma and ensuring that Service personnel have access to high quality confidential assessment and treatment remain priorities for the UK Armed Forces.

Cost-effectiveness analysis of aripiprazole vs standard-of-care in the management of community-treated patients with schizophrenia: STAR study

Abstract Background: The Schizophrenia Trial of Aripiprazole (STAR) showed superior efficacy for aripiprazole compared with atypical antipsychotic standard-of-care (SOC) for the community treatment of schizophrenia 1 based on the Investigator Assessment Questionnaire total score.

OBJECTIVE

To determine the cost-effectiveness of aripiprazole compared with SOC medications from a health and social care system perspective.

METHODS

Information on health and social care service use was collected using the Client Socio-demographic and Service Receipt Inventory (CSSRI). Unit costs attached to each service were used to calculate patients' healthcare and other costs. The primary outcome measure was Investigator's Assessment Questionnaire (IAQ) score; secondary measures included the Clinical Global Impression (CGI)-Improvement response and Quality of Life Scale (QLS). Incremental cost-effectiveness was measured over 26 weeks as the ratio of the difference in mean costs between aripiprazole and SOC (olanzapine, quetiapine and risperidone) to the difference in mean outcomes. Net benefit was used to plot the cost-effectiveness acceptability curve.

RESULTS

The analysis sample (all randomised subjects who met the study inclusion criteria) included 282 individuals randomised to aripiprazole and 266 to SOC (olanzapine, n = 75; quetiapine, n = 110 and risperidone, n = 81). The additional mean cost of achieving a clinically significant difference on the IAQ was £3896, where a clinically significant difference was taken to be an 8-point improvement. The cost-effectiveness acceptability curve for the IAQ indicated that aripiprazole has a relatively high probability of being viewed as cost-effective for a range of plausible values attached to the incremental outcome difference. Additional costs of a clinically significant improvement on the CGI-Improvement and QLS were £575 and £835, respectively. These measures therefore support the view that aripiprazole is more cost-effective than SOC from a health and social care perspective for people with schizophrenia treated in the community.

CONCLUSION

In the STAR study, use of aripiprazole in the management of patients with schizophrenia was cost-effective.

Accuracy of self-reports of mental health care utilization and calculated costs compared to hospital records

Assessments of service utilization is often based on self-reports. Concerns regarding the accuracy of self-reports are raised especially in mental health care. The purpose of this study was to analyze the accuracy of self-reports and calculated costs of mental health services. In a prospective cohort study in Germany, self-reports regarding psychiatric inpatient and day-care use collected by telephone interviews based on the Client Socio-Demographic and Service Receipt Inventory (CSSRI) as well as calculated costs were compared to computerized hospital records. The sample consisted of patients with mental and behavioral disorders resulting from alcohol (ICD-10 F10, n=84), schizophrenia, schizophrenic and delusional disturbances (F2, n=122) and affective disorders (F3, n=124). Agreement was assessed using the concordance correlation coefficient (CCC), mean difference (95% confidence intervals (CI)) and the 95% limits of agreement. Predictors for disagreement were derived. Overall agreement of mean total costs was excellent (CCC=0.8432). Costs calculated based on self-reports were higher than costs calculated based on hospital records (15 EUR (95% CI -434 to 405)). Overall agreement of total costs for F2 patients was CCC=0.8651, for F3 CCC=0.7850 and for F10 CCC=0.6180. Depending on type of service, measure of service utilization and costs agreement ranged from excellent to poor and varied substantially between individuals. The number of admissions documented in hospital records was significantly associated with disagreement. Telephone interviews can be an accurate data collection method for calculating mean total costs in mental health care. In the future more standardization is needed.

Utilisation of Healthcare and Associated Services in Huntington's disease: a data mining study

Background: People with Huntington’s disease (HD) often require tailored healthcare and support packages that develop as the disease progresses. The Client Service Receipt Inventory (CSRI) gathers retrospective information on service utilization. This study investigated the use of formal services and informal care as measured by the CSRI and explored associations between informal care, disease severity and functional ability as measured by the Unified Huntington’s Disease Rating Scale Total Motor Score (UHDRS-TMS) and functional scales.

Methods: All monitored longitudinal data from annual clinical assessments of UHDRS-TMS and functional assessments and CSRI collected under the auspices of the European Huntington’s Disease Network (EHDN) REGISTRY study between the years 2004 and 2009 were utilised in the analyses. Disease severity was reflected by UHDRS-TMS. Functional ability was measured using the UHDRS functional scales. CSRI data were analysed according to percentage use of individual formal services and total estimated hours per week of informal care. Regression analyses were conducted to identify any associations between disease severity, functional ability and hours of informal care.

Results: 451 HD patients (212 female; 239 male) completed one visit; 105 patients (54 females; 51 males) completed two visits and 47 patients (20 females; 27 males) completed three visits in total over the 5 year period. The mean time between visits was 1.2 years. At visit one, 74% of the participants reported being in receipt of at least one formal hospital-based service in the previous six months, and 89% reported receipt of formal primary and community care services. In contrast, at the third visit, 62% of people had used hospital based services and 94% formal community based services in the previous six months. Fifty % of individuals required some form of informal care in the home at visit 1; this increased to 68% at visits 2 and 3. The mean (SD) estimated weekly total informal care hours at visits 1, 2 and 3 were 32.8 (49.4); 21.6 (53.6) and 21.3 (62.4) respectively. Only the scores on the Functional Assessment Scale (FAS) accounted for the variance in the weekly total informal care hours at each visit.

Conclusions: Although it must be acknowledged that service use is supply driven, most HD patients across Europe surveyed as part of this study were in receipt of formal primary and community care services and to a lesser extent formal hospital based services. There was however a large reliance on informal care in the home. The FAS appear to have predictive value on informal care requirements and may have utility in facilitating pro-active service provision and in particular when managing carer burden in this population.

Cognitive behavioural therapy versus supportive therapy for persistent positive symptoms in psychotic disorders: the POSITIVE Study, a multicenter, prospective, single-blind, randomised controlled clinical trial

BACKGROUND

It has been demonstrated that cognitive behavioural therapy (CBT) has a moderate effect on symptom reduction and on general well being of patients suffering from psychosis. However, questions regarding the specific efficacy of CBT, the treatment safety, the cost-effectiveness, and the moderators and mediators of treatment effects are still a major issue. The major objective of this trial is to investigate whether CBT is specifically efficacious in reducing positive symptoms when compared with non-specific supportive therapy (ST) which does not implement CBT-techniques but provides comparable therapeutic attention.

METHODS/DESIGN

The POSITIVE study is a multicenter, prospective, single-blind, parallel group, randomised clinical trial, comparing CBT and ST with respect to the efficacy in reducing positive symptoms in psychotic disorders. CBT as well as ST consist of 20 sessions altogether, 165 participants receiving CBT and 165 participants receiving ST. Major methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, analysis by intention to treat, data management using remote data entry, measures of quality assurance (e.g. on-site monitoring with source data verification, regular query process), advanced statistical analysis, manualized treatment, checks of adherence and competence of therapists. Research relating the psychotherapy process with outcome, neurobiological research addressing basic questions of delusion formation using fMRI and neuropsychological assessment and treatment research investigating adaptations of CBT for adolescents is combined in this network. Problems of transfer into routine clinical care will be identified and addressed by a project focusing on cost efficiency.

DISCUSSION

This clinical trial is part of efforts to intensify psychotherapy research in the field of psychosis in Germany, to contribute to the international discussion on psychotherapy in psychotic disorders, and to help implement psychotherapy in routine care. Furthermore, the study will allow drawing conclusions about the mediators of treatment effects of CBT of psychotic disorders.

Correlates of quality of life in an Arab schizophrenia sample

OBJECTIVES

We focused on the subjective quality of life (QOL) indicators of the Lancashire quality of life profile, European version (LQoLP-EU) in a Kuwaiti schizophrenia sample. The objectives were: First, to assess the reliability and validity of the questionnaire. Second, to highlight the patients' QOL profile, in comparison with the results of the European five-nation study. Third, to examine the association of perceived needs for care, caregiver burden, service satisfaction, self-esteem and psychopathology, with three indices of global QOL: total life satisfaction or perceived QOL (PQOL) score; general wellbeing (GW) and Cantril's ladder (CL).

METHOD

Consecutive outpatients in stable condition and their family caregivers were interviewed with the LQoLP, and measures of needs for care, service satisfaction, caregiver burden and psychopathology.

RESULTS

There were 130 patients (66.1%m, mean age 36.8). Majority of the patients (56%) felt satisfied with the nine domains of life investigated, and 44.6% felt "averagely" happy. Their clinical severity was moderate (BPRS-18 = 44.4). In exploratory factor analysis (FA), the original domains were mostly replicated. Reliability indices were significant (>0.7). In stepwise regression analyses, the associations of PQOL were more in number and mostly different from those of GW and CL. The correlates of PQOL included, social unmet need (8.1% of variance), staff perception of unmet need (10.3%), general satisfaction with services (11.3%), burden of caregiver supervision (3.7%), self-esteem (2.9%) and positive symptoms (2.6%). Of the nine life domains, health was the most important correlate of GW and CL, indicating the centrality of health status in judgments of subjective QOL. In secondary FA, GW and CL loaded together, but separately from life domains, implying that these are separable parts of the subjective wellbeing construct.

CONCLUSION

The profile of QOL scores was mostly similar to European data. The significant multivariate association with patients/staff perceptions of unmet need for care and service satisfaction indicate the usefulness of staff professional development and service improvement in outcome; and imply that promotion of QOL should be an institutional objective. Our finding about the relationship between the three global measures of QOL has added support to the emerging QOL theory.

Help-seeking and receipt of treatment among UK service personnel

BACKGROUND

For armed forces personnel, data on help-seeking behaviour and receipt of treatment for mental disorders are important for both research and policy.

AIMS

To examine mental healthcare service use and receipt of treatment in a sample of the UK military.

METHOD

Participants were drawn from an existing UK military health cohort. The sample was stratified by reserve status and by participation in the main war-fighting period of the Iraq War. Participants completed a telephone-based structured diagnostic interview comprising the Patient Health Questionnaire and Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD), and a series of questions about service utilisation and treatment receipt.

RESULTS

Only 23% of those with common mental disorders and still serving in the military were receiving any form of medical professional help. Non-medical sources of help such as chaplains were more widely used. Among regular personnel in receipt of professional help, most were seen in primary care (79%) and the most common treatment was medication or counselling/psychotherapy. Few regular personnel were receiving cognitive-behavioural therapy (CBT). These findings are comparable with those reported for the general population.

CONCLUSIONS

In the UK armed forces, the majority of those with mental disorders are not currently seeking medical help for their symptoms. Further work to understand barriers to care is important and timely given that this is a group at risk of occupational psychiatric injury.

Cognitive remediation therapy in schizophrenia: cost-effectiveness analysis

PURPOSE

There is a lack of evidence on the cost-effectiveness of cognitive remediation therapy (CRT).

METHODS

Randomised controlled trial comparing usual care plus CRT with usual care alone. Participants had a diagnosis of schizophrenia and cognitive and social functioning difficulties. Health/social care and societal costs were estimated at 14 weeks (time 2) and 40 weeks (time 3) after randomisation. The outcome, proportion of participants improving their working memory since baseline, was combined with costs to explore cost-effectiveness.

RESULTS

85 participants were recruited. There were no differences in total health/social care or societal costs between the two groups at either time 2 or time 3. An additional 21% of participants in the CRT group improved their working memory at both follow-ups. When placing these cost and outcomes in hypothetical scenarios concerning how much policy-makers would pay for another 1% of participants improving their working memory, there was more than an 80% chance that CRT would be cost-effective compared to usual care; at time 3, the likelihood of cost-effectiveness peaked at 30% even for investments up to pound 5000.

CONCLUSIONS

CRT can improve memory among people with schizophrenia and cognitive deficits at no additional cost. Although cost-effective in the short term, CRT may have limited potential to save costs in the medium term because it could increase take up of services. This could confer important longer term benefits for the patient group examined here, in terms of improved social functioning and less reliance on services. This can only be ascertained through longer follow-up.

Frequent attendance in primary care: comparison and implications of different definitions

BACKGROUND

The diversity of definitions of frequent attendance in the literature hampers comparison of their precision, validity, and associated factors.

AIM

To examine different definitions of frequent attendance in order to identify the sociodemographic and clinical factors associated with frequent attendance in primary care, according to each definition.

DESIGN OF STUDY

One-phase cross-sectional study.

SETTING

Seventy-seven primary care centres in Catalonia, Spain.

METHOD

A total of 3815 primary care patients were interviewed between October 2005 and March 2006. Three definitions of frequent attendance were tested: (1) frequent attenders as the top 25% and the top 10% consulting patients; (2) frequent attenders as the top 25% and the top 10% consulting patients stratified by age and sex; and (3) frequent attenders as the top 25% and the top 10% consulting patients stratified by the presence of physical/mental conditions (patients with only mental disorders, with only chronic physical conditions, with comorbid conditions, and with no condition). Multilevel logistic regressions were used.

RESULTS

The following factors were systematically related to frequent attender status: being on sick leave, being born outside of Spain, reporting mental health problems as the main reason for consulting, and having arthritis/rheumatism, or bronchitis. Major depression was related to frequent attendance in two of the three definitions. The factor 'GP' was related to frequent attendance when the top decile cut-off point was used. The models with a 10% cut-off point were more discriminative than those with a 25% cut-off point: the area under the receiver operating characteristic curve for models with a 25% cut-off and a 10% cut-off ranged between 0.71 (95% confidence interval [CI] = 0.70 to 0.73) and 0.75 (95% CI = 0.74 to 0.77) and between 0.79 (95% CI = 0.78 to 0.81) and 0.85 (95% CI = 0.83 to 0.86), respectively.

CONCLUSION

The way frequent attendance is defined is of crucial importance. It is recommended that a more discriminative definition of frequent attendance is used (the top 10%).

Long term outcome of primary care depression

We conducted a follow up over 23 years of depressed patients originally presenting to general practice in 1981 and studied in detail at that time. Aims were to assess the long term course and outcome of depression in primary care. Patterns of recovery and recurrence of major depressive episodes, together with other aspects of course, treatment and current state, were assessed at interview. 78% (129) of the original sample were traced to current general practice and outcome data obtained on 54. One third had a prior history of depression. Interview data were obtained on 37 patients. Time to recovery from baseline averaged 10.3 months. The recurrence rate was 64% (23). Most participants suffered at least 2 further episodes that were frequently chronic lasting 2 years on average. Time before first recurrence appeared considerably longer than in comparable psychiatric inpatient samples. No participants were continuously ill. Although loss to follow up limits our conclusions, the course of primary care depression appears worse than suggested by previous, shorter follow ups. Our data suggest that long term risk of a recurrence may be high, but with recurrence delayed.

Cost of treatment of schizophrenia in six European countries

BACKGROUND AND AIMS

As part of an RCT in six European sites, the direct mental health care cost for 422 patients with schizophrenia was analysed according to how total and medication costs differed across sites and which variables were likely to predict total or service-specific costs.

METHOD

Service use was recorded continuously during a 12-month follow-up. Prescribed psychotropic medication was recorded at baseline and 12 months later. Service use data were transformed into EURO, log-transformed and analysed using linear regression models.

RESULTS

Although samples were homogeneous, large inter-site cost differences were found (annual means ranging from 2958 euro in Spain up to 36978 euro in Switzerland). Psychopharmacologic costs were much more constant across sites than costs for other services. Total costs were associated more with region or socio-demographic characteristics than with disorder related parameters.

CONCLUSIONS

The findings confirm remarkable differences in direct costs of patients with schizophrenia across Europe. However, the relative stability of medication costs suggests a need to analyse mechanisms that influence service-specific costs for schizophrenia.

Predictors of general quality of life and the mediating role of health related quality of life in patients with schizophrenia

INTRODUCTION

The concept 'quality of life' (QoL) has become increasingly important as an outcome measure in the evaluation of services and in clinical trials of people with schizophrenia. This study examines the mediating role of health related quality of life (HRQoL) in the prediction of general quality of life (GQoL).

METHOD

QoL and other patient- and illness characteristics (psychopathology, overall functioning, illness history, self-esteem and social integration) were measured in a group of 143 outpatients with schizophrenia. GQoL was measured by the Lancashire Quality of Life Profile and HRQoL was measured by the MOS SF-36. To test the temporal stability of our findings, assessments were performed twice with an 18-month interval.

RESULTS

We found that patient's GQoL is predicted mainly by anxiety and depression and self-esteem and to a lesser extent by global functioning and social integration. At both time intervals HRQoL appeared to be a significant mediator of the relationship between anxiety and depression and self esteem versus patient's GQoL.

CONCLUSIONS

The results of this study are important for mental health professionals, as these provide more insight in the mechanisms by which they could improve the GQoL of their patients with schizophrenia. The results confirm that diagnosis and treatment of anxiety and depression in outpatients with schizophrenia deserves careful attention of clinicians. Also strategies and specific interventions to improve self-esteem of patients with schizophrenia are very important to maximise patient's QoL.

The identification of young people's emotional distress: a study in primary care

BACKGROUND

Primary care is a key step in young people's pathway to mental health care. Despite the high prevalence of mental disorder in this age group, little is known about the factors that determine the identification of young people's mental disorder in primary care.

AIM

To provide a detailed description of the factors associated with both 'correct' and 'excessive' identification of youth mental disorder in primary care.

DESIGN OF THE STUDY

Cross-sectional study.

SETTING

Twenty-six randomly selected general practices in Victoria, Australia.

METHOD

Consecutive young people (16-24 years) were interviewed before their consultation, using a semi-structured interview. They completed Kessler's scale of emotional distress (K10). GPs completed a questionnaire after the consultation. Multinomial logistic regression was used to examine the factors associated with GP identification of mental disorder in those with high and low probability of disorder on the K10.

RESULTS

Altogether, 450/501 (90%) of approached young people participated; 36.1% (95% confidence interval [CI] = 32.3 to 40.2%) had high probability of mental disorder on the K10. Young people's perception that they had a mental illness was highly associated with GP identification (odds ratio [OR] = 62.6, 95% CI = 22.8 to 172.0). Other significantly associated factors were: patient fears (OR = 2.4, 95% CI = 1.1 to 5.1), frequent consultations (OR = 3.0, 95% CI = 1.0 to 8.4), days out of role (OR = 2.7, 95% CI = 1.2 to 5.7), and continuity of care (OR = 3.4, 95% CI = 1.6 to 6.9). The latter two were also associated with 'over-identification' of young people who had low probability of mental disorder. GP characteristics were not associated with identification.

CONCLUSION

These findings provide guidance for GPs in their clinical work and training. They should also inform the further development of mental health literacy programmes in the community.

Collaboration in outpatient antipsychotic drug treatment: analysis of potentially influencing factors

Knowledge of factors relevant for medication adherence and patient collaboration is still limited. Our study aims at exploring the contribution of a variety of factors to collaboration in outpatients with schizophrenia and schizoaffective disorder. We obtained self-rated and observer-rated data from 108 outpatients during an interview 6 months after hospital discharge. The compliance rating scale (CRS) classified 76% of the patients as collaborative. Factors related to the patient, illness, treatment, and social environment were analysed in two-step explorative correlation and regression analyses in order to determine their relative contribution to collaboration. Only trust in medication and lack of insight were associated with collaboration, and they accounted for 38% of the variance. Neither medication side effects nor neuropsychological functioning correlated with collaboration. The conceptualisation of medication adherence is complex, and there are a number of unresolved methodological problems. The data indicate that illness and treatment-related subjective attitudes may be more relevant than side effects, cognitive functioning or any sociodemographic variable.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): design and methods

Background

Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.

Methods

This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.

The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.

Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.

Discussion

If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.

Trial Registration

ISRCTN59603527

SF-36 scales, and simple sums of scales, were reliable quality-of-life summaries for patients with schizophrenia

OBJECTIVE

To examine the feasibility and reliability of the Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) for patients with schizophrenia, focusing on the eight scales and various aggregate summary measures.

STUDY DESIGN AND SETTING

Secondary analysis of data from the European multicenter QUATRO medication adherence trial and the Regional Psychosis Project from The Netherlands. Methods included exploratory and confirmatory factor analyses and estimation of aggregate score reliability using Cronbach's alpha and Tarkkonen's generalized reliability index. The aggregate scores that were compared included two sets based on factor analyses, the standard "physical and mental health component summary scores" (PCS and MCS) and scores based on the original conceptual model of the SF-36 (simple sum of first four scales for physical health, last four for mental health).

RESULTS

The eight SF-36 scales were feasible to administer and reliable. Factor analyses of the QUATRO baseline scale data suggested two or three factors, the latter solution including a general "role limitation" factor. Aggregate scores based on the conceptual model had the highest generalized reliability of those compared.

CONCLUSION

SF-36 scales are suitable for patients with schizophrenia. Aggregate scores based on the conceptual model may be preferable to the MCS and PCS for such patients. Further investigation of factor structure is advisable.

Assessment of medication adherence in patients with schizophrenia: the Achilles heel of adherence research

Measuring medication adherence in patients with schizophrenia is difficult and lacks a gold standard. Consequently, a great number of different methods and instruments have been proposed. Although it has been assumed that they all measure medication adherence, this study demonstrates that instruments differ significantly. Using data from an international multisite study (N = 329), we found that 3 questionnaires, designed to measure medication adherence and typical for instruments used in studies in patients with schizophrenia, do not agree in labeling patients as nonadherent. Further, they seem not to measure the same trait, are related to different established risk factors of nonadherence, and are only weakly related to these established risk factors of nonadherence. If these results are representative of the validity of other measures used in adherence research, this may have serious consequences for the interpretation of, and explanations for discrepancies found in the literature. Researchers should be aware of this problem and continue to combine objective and subjective methods in the hope of increasing the reliability and validity of measures of adherence.

The protocols for the 10/66 dementia research group population-based research programme

BACKGROUND

Latin America, China and India are experiencing unprecedentedly rapid demographic ageing with an increasing number of people with dementia. The 10/66 Dementia Research Group's title refers to the 66% of people with dementia that live in developing countries and the less than one tenth of population-based research carried out in those settings. This paper describes the protocols for the 10/66 population-based and intervention studies that aim to redress this imbalance.

METHODS/DESIGN

Cross-sectional comprehensive one phase surveys have been conducted of all residents aged 65 and over of geographically defined catchment areas in ten low and middle income countries (India, China, Nigeria, Cuba, Dominican Republic, Brazil, Venezuela, Mexico, Peru and Argentina), with a sample size of between 1000 and 3000 (generally 2000). Each of the studies uses the same core minimum data set with cross-culturally validated assessments (dementia diagnosis and subtypes, mental disorders, physical health, anthropometry, demographics, extensive non communicable disease risk factor questionnaires, disability/functioning, health service utilisation, care arrangements and caregiver strain). Nested within the population based studies is a randomised controlled trial of a caregiver intervention for people with dementia and their families (ISRCTN41039907; ISRCTN41062011; ISRCTN95135433; ISRCTN66355402; ISRCTN93378627; ISRCTN94921815). A follow up of 2.5 to 3.5 years will be conducted in 7 countries (China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Argentina) to assess risk factors for incident dementia, stroke and all cause and cause-specific mortality; verbal autopsy will be used to identify causes of death.

DISCUSSION

The 10/66 DRG baseline population-based studies are nearly complete. The incidence phase will be completed in 2009. All investigators are committed to establish an anonymised file sharing archive with monitored public access. Our aim is to create an evidence base to empower advocacy, raise awareness about dementia, and ensure that the health and social care needs of older people are anticipated and met.

Cost-of-illness studies of depression: a systematic review

BACKGROUND

Depression is a very common disease with substantial economic consequences. This paper reviews all published cost-of-illness studies of depression worldwide.

METHODS

A systematic search of cost-of-illness studies of depression in the databases MEDLINE, Web of Science, Cochrane Library, and PSYNDEXplus was conducted. Identified studies were classified by their basic characteristics. Costs reported were inflated in original currency to the year 2003 and then converted into US-dollar using purchasing power parities (US$ PPP). Additionally, national-costs were converted in costs per case and per inhabitant.

RESULTS

24 papers with notable methodical differences were identified and classified by their basic characteristics. Summary estimates from the studies for the average annual costs per case ranged from $1000 to $2500 for direct costs, from $2000 to $3700 for morbidity costs and from $200 to $400 for mortality costs. The basic quantity of interest in COI-studies of depression was stated.

LIMITATIONS

Methodical differences limited comparison substantially.

CONCLUSIONS

Depression is associated with a high economic burden. Conducting COI-studies of depression along the line noted in the review could help provide the opportunity to expose differences in costs associated with different approaches to disease management.

The impact of caregivers' characteristics, patients' conditions and regional differences on family burden in schizophrenia: a longitudinal analysis

OBJECTIVE

Impact of caregiver characteristics, patient variables, and regional differences on family burden.

METHOD

Two hundred and eighteen schizophrenia patients and key-relatives of an urban and a rural area were examined five times over 30 months. Patients' psychopathology, service utilization; relatives' burden, coping abilities and contact duration with the patients were recorded. Effects of interpersonal differences and intrapersonal changes over time were analyzed with regression models.

RESULTS

Interpersonal differences (patients' positive and negative symptoms, relatives' coping abilities, and patient contact) and intrapersonal changes (relatives' coping abilities, patients' negative symptoms and utilization of community care) predicted family burden.

CONCLUSION

Family education programs should help caregivers to improve their coping strategies. Therapy solutions must address negative symptoms just as much as positive symptoms, as these especially impact caregivers. Intensified community-based care can reduce burden, but provision alone is not sufficient. Psychiatrists and caregivers should motivate patients to take advantage of such offers.

Schizophrenia patients with cognitive deficits: factors associated with costs

Cognitive deficits in people with schizophrenia are associated with poor functioning and lower quality of life. Because few studies have examined their relationship with service use or costs, it is unclear whether effective cognitive remediation interventions have potential for economic impacts. This study examined associations between cognition and costs among people with schizophrenia. Baseline data collected between 1999 and 2002 from a randomized controlled trial of cognitive remediation therapy were analyzed. A total of 85 participants were recruited from a London mental health trust if they had a diagnosis of schizophrenia, evidence of cognitive/social functioning difficulties, and at least 1 year since first contact with psychiatric services. Cognition levels, social functioning, symptoms, sociodemographic characteristics, and retrospective use of health/social care and other resources were measured. Average public sector costs were estimated to be 15 078 pounds(23 824 dollars) for a 6-month period. Associations between health/social care costs and type and severity of cognition were examined using structural equation models. No significant relationships were found between cognition and costs in a model based on 3 independent constituent components of cognition (cognitive shifting, verbal working memory, and response inhibition), although a model with covarying cognition components fitted the observed data well. A model with cognition as a single construct both fitted well and showed a significant relationship. In people with schizophrenia and severe cognitive impairment, improvements in either overall cognition or specific cognitive components may impact on costs. Further investigation in larger samples is needed to confirm this finding and to explore its generalizability to those with less severe deficits.

Adherence to medication and quality of life in people with schizophrenia: results of a European multicenter study

Quality of life is often severely impaired in people with schizophrenia, and adherence to antipsychotic medication has been consistently found to be low in this population. Although there is a considerable amount of evidence on these two variables in schizophrenia research, there is only limited knowledge on how they relate to one another. The aim of this study is to develop a meaningful model of the relationship between quality of life and adherence that includes mediating variables. A multicenter randomized controlled trial recruited 409 subjects in London, Verona, Amsterdam, and Leipzig. Baseline interviews obtained data on adherence, quality of life, and other variables. We used graphical modeling to investigate the relationships between the variables. No direct relation could be discerned between subjective quality of life and adherence to medication. Mediating variables, most importantly symptomatic impairment, global functioning, and medication side effects, were identified by the model. It can be concluded that, when aiming at the improvement of quality of life in people with schizophrenia, variables other than adherence, i.e., symptomatic impairment, global functioning, and medication side effects, should be targeted.

Outcome of major depression in Ethiopia: population-based study

BACKGROUND

The outcome and impact of major depression in developing countries are not clear.

AIMS

To describe the outcome of major depression and compare the disability and patterns of service use among different outcome groups.

METHOD

In a case cohort study, nested within a population-based survey of 68,000 participants using the Composite International Diagnostic Interview (CIDI), 300 participants were randomly selected from those with current major depression and 300 from those with no lifetime history. Participants were re-interviewed after 18-62 months to ascertain current diagnosis, psychological symptoms, disability and use of health services.

RESULTS

Of participants with major depression at baseline 26% also met criteria for major depression at follow up. Mortality ratio standardised for age and gender was 3.55 (95% C11.97 to 6.39). All indices of measure of disability were significantly higher in the persistently depressed group compared with the completely recovered group. Participants who had recovered partially resembled participants with persistent depression. Two-thirds of those with persistent depression had not sought any help.

CONCLUSIONS

Major depression was associated with mortality and disability. Those with residual symptoms remained disabled. Help-seeking was unusual.

Characteristics and health status change over 6 months in people with moderately severe to severe Alzheimer's disease in the U.K

BACKGROUND AND OBJECTIVES

Until recently, attention and treatment strategies have focused mainly on patients in the early phases of Alzheimer's disease (AD). The objectives of this study were to collect information on moderately severe and severe AD patients (Mini-mental State Examination score < 15) in terms of epidemiological, clinical and economic characteristics and disease change in the later stages of AD, and to compare this specific AD population over 6 months with those in the earlier stages.

METHODS

This descriptive analysis recruited institutionalized patients and patients living within the community from the city of London and the South-East region of the U.K. Subgroup analyses at baseline and 6 months were performed using the study population from the London and South-East Region Alzheimer's Disease (LASER-AD) Study. Data from a range of clinical scales, a quality of life (QOL) scale and a resource-utilization questionnaire were analyzed.

RESULTS

People with moderately severe or severe AD are a heterogeneous group with varying QOL, cognitive and functional disabilities, neuropsychological symptoms and relatively low health care resource consumption. This patient group continued to decline but progression of the disease was observed only in some domains.

CONCLUSION

Even at the later stages of AD, patients show varying rates of decline. Improved knowledge about the characteristics and progression of the disease reveals that moderately severe and severe patients cannot be regarded as beyond help and have the potential to experience varying and even high levels of QoL.

Home versus outpatient administration of intravenous steroids for multiple-sclerosis relapses: a randomised controlled trial

BACKGROUND

Intravenous steroids are routinely used to treat disabling relapses in multiple sclerosis, and can be administered in an outpatient or home setting. We developed a rating scale that allowed us to compare the two strategies formally in a trial setting.

METHODS

Patients who had a clinically significant multiple-sclerosis relapse within 4 weeks of onset were randomly assigned administration of a 3-day regimen of intravenous methylprednisolone either in an outpatient clinic (n=69) or at home (n=69). The MS relapse management scale (MSRMS) was developed to measure patients' experiences of relapse management as the primary outcome. Efficacy of the two treatment modalities was compared in terms of traditional measures and economic cost. A cost-minimisation analysis was also done. Analysis was by intention to treat.

FINDINGS

Of 149 eligible patients, 138 consented to participate in the trial and were randomly assigned to a treatment group. Coordination of care was significantly better in the home-treatment group (median score 4.5 [IQR 3.0-11.4]) than in the hospital-treatment group (12.1 [3.0-18.6]; p=0.024). The other dimensions of the MSRMS did not differ between groups (p>0.10). Administration of steroids was equally safe and effective in either location, and cost was either the same or cheaper when delivered at home than when delivered in hospital.

INTERPRETATION

Treatment of relapses in multiple sclerosis with intravenous steroids can be effectively and safely administered at home, from both patient and economic perspectives. Moreover, the trial indicates the importance of explicit and valid outcome measures of all aspects of service delivery when making decisions about health policy. This finding has implications for complex service delivery care models for long-term diseases.

Main determinants of Global Assessment of Functioning score in schizophrenia: a European multicenter study

BACKGROUND

The Global Assessment of Functioning (GAF) scale is a measure widely used to assess the outcome of patients with schizophrenia. However, little is known about the importance of clinical and psychosocial variables in determining its final score. The aim of this paper is to identify which factors predict GAF scores of patients with schizophrenia and their variability in 5 different European settings.

METHOD

A representative sample of 404 patients with schizophrenia was assessed with the GAF. A multiple regression analysis was performed to identify predictors of the GAF scores.

RESULTS

Clinical factors are the main determinants of GAF score. However, the analysis also showed that social and functioning factors were also significantly associated with GAF scores. Finally, the study showed the presence of intercenter differences in the factors, mainly in social functioning.

CONCLUSIONS

The GAF is a useful and easy-to-apply measure of global functioning, independent of cross-cultural differences. Clinical factors are the main determinants of its score, although social functioning variables also have a lesser effect.