Discontinuation vs. continuation treatment with neuroleptics for a better long-term outcome

Background

Long-term functional outcome of dose-reduction/discontinuation strategies in first-episode psychosis (FEP) has not been studied before. The present study compared 7-year outcome of an early antipsychotic dose-reduction/discontinuation (DR) strategy with maintenance treatment (MT). Primary outcome was (symptomatic and functional) recovery; relapse rates, functional and symptomatic remission were secondary outcomes.

Methods

FEP patients (n = 128) symptomatically remitted for 6 m during their first treatment year who completed an 18 months trial comparing MT and DR were followed-up at 7 years. Symptomatic remission criteria were adopted from Andreasen et al., functional remission criteria were based on a functioning scale. Recovery was defined as meeting both criteria sets. MT or DR strategy, and baseline parameters were entered in a logistic regression analysis with symptom and functional remission and recovery at 7-years follow-up as dependent variables.

Results

One hundred and three patients consented to participate. DR-patients showed twice the recovery-rate of MT-patients (40% against 18%), odds ratio 3.5 (P = .014). Symptomatic remission-rates were equal (69% and 67%). Better DR recovery-rates were attributable to higher functional remission-rates (46% vs. 20%) in DR. Predictors of recovery were DR, baseline living together and less severe negative symptoms. During the last 2 years of follow-up the mean daily dose in haloperidol equivalents was 2.20 mg in DR vs. 3.60 mg in MT (P = .031).

Relapse rates were initially higher in DR but leveled at 3 years; 61.5% relapsed in DR and 68.6% in MT in 7 years.

Conclusion

DR of antipsychotics during early stages of remitted FEP significantly improved 7-years outcome in terms of recovery and functional remission compared to maintenance treatment. Though initially relapse rates in GD were higher, these equalled those in MT from 3 years to the end of the study. While the necessity of immediate antipsychotic treatment in FEP and positive symptoms relapse is robustly demonstrated in a great number of studies, this study suggests that we are faced with a dilemma concerning the drawbacks of long-term maintenance antipsychotic treatment on functional capacity. Though antipsychotic discontinuation appears only feasible without relapse in a substantial minority of patients, guided dose-reduction as far as positive symptoms remain subsided and allow it, appears a feasible strategy in view of functional recovery, doing justice to both sides of the dilemma.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Working effectively towards rehabilitation goals: long-term outcome of a randomised controlled trial of the Boston psychiatric rehabilitation approach]

BACKGROUND

In the Netherlands the Boston psychiatric rehabilitation approach (bpr) is one of the most widely implemented rehabilitation methods. So far, little research has been done on the efficacy of this approach.

AIM

To investigate the effect of bpr on the attainment of personal rehabilitation goals, social functioning and empowerment and on care requirements and quality of life in persons with severe mental illness (smi) in the Netherlands.

METHOD

In a multicentre randomised controlled trial (rct:

CLINICAL TRIAL REGISTRATION NUMBER

isrctn73683215) patients with smi were randomly assigned to bpr (n = 80) or 'care as usual' (cau; n = 76). The primary outcome was the attainment of the rehabilitation goal as formulated by the patient. The secondary outcomes were a change in the work situation and in the degree of independent living, in care requirements (Camberwell Assessment of Needs), in empowerment (Personal Empowerment Scale) and in the quality of life (who-qol). The effects were tested at 12 and 24 months.

RESULTS

The degree of goal attainment was substantially higher in bpr at both 12 months (adjusted risk difference: 16%; 95%ci, 2 to 31; nnt = 7) and 24 months (adjusted risk difference: 21%, 95%ci, 4% to 38%; nnt = 5). The approach was also more effective in the area of societal participation (bpr: 21% adjusted increase, cau: 0% adjusted increase; nnt = 5), but not in the other secondary outcome measures.

CONCLUSION

The results suggest that bpr is effective in supporting patients with smi to reach self-formulated rehabilitation goals and in enhancing their societal participation.

Childhood abuse and neglect in relation to the presence and persistence of psychotic and depressive symptomatology

BACKGROUND

The association between childhood trauma and psychotic and depressive symptomatology is well established. However, less is known about the specificity and course of these symptoms in relation to childhood trauma.

METHOD

In a large sample (n = 2765) of patients with psychosis (n = 1119), their siblings (n = 1057) and controls (n = 589), multivariate (mixed-effects) regression analyses with multiple outcomes were performed to examine the association between childhood trauma and psychotic and depressive symptomatology over a 3-year period.

RESULTS

A dose-response relationship was found between childhood trauma and psychosis. Abuse was more strongly associated with positive symptoms than with negative symptoms whereas the strength of the associations between neglect and positive and negative symptoms was comparable. In patients, similar associations between childhood trauma and psychotic or depressive symptoms were found, and in siblings and controls, stronger associations were found between trauma and depressive symptomatology. Childhood trauma was not related to a differential course of symptoms over a 3-year time period.

CONCLUSIONS

In congruence with earlier work, our findings suggest that childhood trauma, and abuse in particular, is associated with (subthreshold) psychosis. However, childhood trauma does not seem to be associated with a differential course of symptoms, nor does it uniquely heighten the chance of developing (subthreshold) psychotic symptomatology. Our results indicate that trauma may instead contribute to a shared vulnerability for psychotic and depressive symptoms.

[Functional remission of people with serious mental illness (SMI): psychometric properties of a new ROM-instrument]

BACKGROUND

Instruments are used for routine outcome monitoring of patients with severe mental illness in order to measure psychiatric symptoms, care needs and quality of life. By adding an instrument for measuring functional remission a more complete picture can be given of the complaints, the symptoms and general functioning, which can give direction to providing care for patients with severe mental illness.

AIM

To describe the development and testing of a new instrument of functional remission (FR) among people with a psychotic disorder or another serious mental disorder (SMI) as an addition to the symptomatic remission (SR), according to international criteria.

METHOD

The FR-assessment involves assessment by a mental health professional who conducts a semi-structured interview with the patient and his or her family and/or uses patient files relating to the three areas of functioning: daily living and self-care; work, study and housekeeping; and social contacts. These areas are rated on a three-point scale of 0: independent; 1: partially independent; 2: dependent. The assessment covers a period of six months, in accordance with the measurement of symptomatic remission and should be part of regular routine outcome monitoring (ROM) procedures. The FR-instrument was used in 2012 with 840 patients from eight Dutch mental care institutions and included a one-year follow-up among 523 patients (response 62%).

RESULTS

The results showed that the instrument is relatively easily to complete. It was also relevant for clinical practice, although further research is needed because of the raters' low response. Intra- and inter-rater reliability, discriminating and convergent validity, and sensitivity to change were rated sufficient to good.

CONCLUSION

If the FR-instrument becomes part of regular ROM-procedures and is used as a measure of societal participation, it could be a useful addition to current measures of symptomatic remission.

Factors contributing to the duration of untreated psychosis

BACKGROUND

Shortening the duration of untreated psychosis (DUP) - with the aim of improving the prognosis of psychotic disorders - requires an understanding of the causes of treatment delay. Current findings concerning several candidate risk factors of a longer DUP are inconsistent. Our aim was to identify factors contributing to DUP in a large sample that represents the treated prevalence of non-affective psychotic disorders.

METHOD

Patients with a non-affective psychotic disorder were recruited from mental health care institutes from 2004 to 2008. Of the 1120 patients enrolled, 852 could be included in the present analysis. Examined candidate factors were gender, educational level, migration status, premorbid adjustment and age at onset of the psychotic disorder. DUP was divided into five ordinal categories: less than one month, one month to three months, three months to six months, six months to twelve months and twelve months and over. An ordinal logistic regression analysis was used to identify the risk factors of a longer DUP.

RESULTS

Median DUP was less than one month (IQR 2). The factors migration status (p=0.028), age at onset of the psychotic disorder (p=0.003) and gender (p=0.034) were significantly associated with DUP in our analysis.

CONCLUSION

First generation immigrant patients, patients with an early onset of their psychotic disorder and male patients seem at risk of a longer DUP. These findings can assist in designing specific interventions to shorten treatment delay.

Insight change in psychosis: relationship with neurocognition, social cognition, clinical symptoms and phase of illness

OBJECTIVE

Impaired insight is an important and prevalent symptom of psychosis. It remains unclear whether cognitive disturbances hamper improvements in insight. We investigated the neurocognitive, social cognitive, and clinical correlates of changes in insight.

METHOD

One hundred and fifty-four patients with a psychotic disorder were assessed at baseline (T0 ) and after three years (T3 ) with the Birchwood Insight Scale, the Positive And Negative Syndrome Scale, measures of neurocognition and social cognition. Linear regression analyses were conducted to examine to what extend neurocognition, social cognition, clinical symptoms and phase of illness could uniquely predict insight change. Subsequently, changes in these factors were related to insight change.

RESULTS

Better neurocognitive performance and fewer clinical symptoms at baseline explained insight improvements. The additional effect of clinical symptoms over and above the contribution of neurocognition was significant. Together, these factors explained 10% of the variance. Social cognition and phase of illness could not predict insight change. Changes in clinical symptoms, but not changes in neurocognitive performance were associated with insight change.

CONCLUSION

Neurocognitive abilities may predict, in part, the development of insight in psychosis.

Risk assessment and shared care planning in out-patient forensic psychiatry: cluster randomised controlled trial

BACKGROUND

Forensic psychiatry aims to reduce recidivism and makes use of risk assessment tools to achieve this goal. Various studies have reported on the predictive qualities of these instruments, but it remains unclear whether their use is associated with actual prevention of recidivism in clinical care.

AIMS

To test whether an intervention combining risk assessment and shared care planning is associated with a reduction in violent and criminal behaviour.

METHOD

A cluster randomised controlled trial (Netherlands Trial Register number NTR1042) was conducted in three out-patient forensic psychiatric clinics. The intervention comprised risk assessment with the Short Term Assessment of Risk and Treatability (START) and a shared care planning protocol formulated according to shared decision-making principles. The control group received usual care. The outcome consisted of the proportion of clients with violent or criminal incidents at follow-up.

RESULTS

In total 58 case managers and 632 of their clients were included. In the intervention group (n = 310), 65% received the intervention at least once. Findings showed a general treatment effect (22% of clients with an incident at baseline v. 15% at follow-up, P<0.01) but no significant difference between the two treatment conditions (odds ratio (OR) = 1.46, 95% CI 0.89-2.44, P = 0.15).

CONCLUSIONS

Although risk assessment is common practice in forensic psychiatry, our results indicate that the primary goal of preventing recidivism was not reached through risk assessment embedded in shared decision-making.

A systematic review of instruments to measure depressive symptoms in patients with schizophrenia

BACKGROUND

Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia. Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms.

OBJECTIVE

We reviewed depression instruments on their reliability and validity in patients with schizophrenia.

METHODOLOGY

A systematic literature search was carried out in three electronic databases. Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications.

RESULTS

Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia. The only self-report was the Beck Depression Inventory (BDI). The Brief Psychiatric Rating Scale-Depression subscale (BPRS-D), Positive and Negative Syndrome Scale-Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated. All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia. The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity).

CONCLUSIONS

We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia. A valid self-report instrument is to be developed for the use in clinical practice.

Age at onset of non-affective psychosis in relation to cannabis use, other drug use and gender

BACKGROUND

Cannabis use is associated with an earlier age at onset of psychotic illness. The aim of the present study was to examine whether this association is confounded by gender or other substance use in a large cohort of patients with a non-affective psychotic disorder.

METHOD

In 785 patients with a non-affective psychotic disorder, regression analysis was used to investigate the independent effects of gender, cannabis use and other drug use on age at onset of first psychosis.

RESULTS

Age at onset was 1.8 years earlier in cannabis users compared to non-users, controlling for gender and other possible confounders. Use of other drugs did not have an additional effect on age at onset when cannabis use was taken into account. In 63.5% of cannabis-using patients, age at most intense cannabis use preceded the age at onset of first psychosis. In males, the mean age at onset was 1.3 years lower than in females, controlling for cannabis use and other confounders.

CONCLUSIONS

Cannabis use and gender are independently associated with an earlier onset of psychotic illness. Our findings also suggest that cannabis use may precipitate psychosis. More research is needed to clarify the neurobiological factors that make people vulnerable to this precipitating effect of cannabis.

Auditory hallucinations in childhood: associations with adversity and delusional ideation

BACKGROUND

Previous work suggests that exposure to childhood adversity is associated with the combination of delusions and hallucinations. In the present study, associations between (severity of) auditory vocal hallucinations (AVH) and (i) social adversity [traumatic experiences (TE) and stressful events (SE)] and (ii) delusional ideation were examined.

METHOD

A baseline case-control sample of children with and without AVH were re-assessed on AVH after 5 years and interviewed about the experience of social adversity and delusions.

RESULTS

A total of 337 children (mean age 13.1 years, S.D.=0.5) were assessed: 40 children continued to hear voices that were present at baseline (24%, persistent group), 15 heard voices only at follow-up (9%, incident group), 130 children no longer reported AVH that were present at baseline (remitted group) and 152 never heard voices (referent group). Both TE and SE were associated with both incident and persistent AVH, as well as with greater AVH severity and delusional ideation at follow-up. In addition, the combination of AVH and delusions displayed a stronger association with TE and SE compared with either AVH or delusions alone.

CONCLUSIONS

Early childhood AVH are mostly benign and transitory. However, experience of social adversity is associated with persistence, severity and onset of new AVH closer to puberty, and with delusional ideation.

Risk factors of auditory hallucinations in childhood: adversity and the formation of psychotic-like ideation

Auditory vocal hallucinations (AVH) in general had limited functional impact in 7–8 year old children. However, transitory developmental expression of psychotic symptoms may become more persistent (and clinically relevant), depending on the degree of exposure to environmental risk factors. Therefore, in a five-year follow-up study of a case-control sample associations of (severity of) AVH with social adversity (traumatic experiences and stressful events) and the formation of delusional ideation were examined. In total 337 children (mean age 13.1 years; SD = 0.5) were reassessed. Forty children had continued to hear voices (24%, persistent group), 15 had heard voices for the first time (9%, incident group), 130 children no longer reported AVH (remitted group) and 152 never heard voices (referent group). Early social adversity was strongly associated with both incident and persistent AVH, and predicted greater AVH severity at follow-up. Children with both AVH and delusions were more likely to have experienced traumatic or stressful events than children with either symptom alone. AVH severity was shown to be a mediator in the association between TE (but not SE) and delusion formation. These results suggest that, although hearing voices in 7–8 year olds is in most cases benign, experience of social adversity can predict persistence and onset of new AVH closer to puberty. Given evidence for the association with delusion formation, they do pose a significant clinical risk.

FC06-03 - Course of auditory vocal hallucinations in childhood: A 5-year follow-up study

Background

In a baseline study among 7–8 year old children with auditory vocal hallucinations (AVH), only limited functional impact of AVH was observed.

Aims

To assess AVH 5-year course and its predictors, as well as AVH 5-year incidence and its risk factors.

Method

A sample of 337 12- and 13-year-old children were reassessed on AVH after a mean follow-up period of 5.1 years. Parents completed the Child Behaviour Checklist (CBCL). School performance was assessed.

Results

The AVH 5-year persistence and incidence rates were 24% and 9% respectively, more new cases arising in urban areas. Both persistent and incident AVH were associated with problem behaviour in the (CBCL) clinical range, particularly at follow-up, as well as with other psychosis-like symptoms, particularly at baseline. AVH persistence was predicted by baseline AVH severity, notably in terms of external attribution of voices and hearing multiple voices, and was associated with worse primary school test scores and lower level secondary school.

Conclusions

First-onset AVH in middle childhood is neither rare nor neutral in terms of psychopathological and behavioural comorbidity. Persistence of AVH in early childhood similarly is not rare and associated with psychopathological, behavioural and cognitive alterations.

The course of depressive symptoms and prescribing patterns of antidepressants in schizophrenia in a one-year follow-up study

BACKGROUND

Antidepressants are frequently prescribed in patients with psychotic disorders, but little is known about their effects in routine clinical practice. The objective was to investigate the prescribing patterns of antidepressants in relation to the course of depressive symptoms in patients with psychotic disorders.

METHODS

A cohort of 214 Dutch patients with psychotic disorders received two assessments of somatic and psychiatric health, including a clinician-rated screening for depressive symptoms, as part of annual routine outcome monitoring.

RESULTS

Depressive symptoms were prevalent among 43% (93) of the patients. Antidepressants were prescribed for 40% (86) of the patients and the majority 83% (71) continued this therapy after one year. Multivariable analysis showed that patients with more severe psychopathology had a higher risk to develop depressive symptoms the following year (OR [95% CI]=0.953 [0.912-0.995]). For patients with depressive symptoms at baseline, polypharmacy was a potential risk factor to keep having depressive symptoms (OR [95% CI]=1.593 [1.123-2.261]). Antidepressant use was not an independent predictor in both analyses.

CONCLUSIONS

Routine outcome monitoring in patients with psychotic disorders revealed a high prevalence of depressive symptoms. Antidepressants were frequently prescribed and continued in routine clinical practice.

Economic aspects of peer support groups for psychosis

Peer support groups are rarely available for patients with psychosis, despite potential clinical and economic advantages of such groups. In this study, 106 patients with psychosis were randomly allocated to minimally guided peer support in addition to care as usual (CAU), or CAU only. No relevant differences between mean total costs of both groups were found, nor were there significant differences in WHOQoL-Bref outcomes. Intervention adherence had a substantial impact on the results. It was concluded that minimally guided peer support groups for psychosis do not seem to affect overall healthcare expenses. Positive results of additional outcomes, including a significant increase in social contacts and esteem support, favour the wider implementation of such groups.

[Typical and atypical antipsychotics: Is there a difference in their influence on neurocognition?]

BACKGROUND

Neurocognitive dysfunction is a core feature of schizophrenia and is related to the functional outcome of the illness. It has been suggested that the so-called atypical antipsychotics may have a more favourable influence on neurocognition than the older, typical antipsychotics and thus also on the functional outcome.

AIM

To review the recent scientific literature concerning the effects of antipsychotics on neurocognition.

METHOD

The literature was reviewed systematically via the most important databases.

RESULTS

Meta-analyses suggest that atypical antipsychotics have moderate, positive effects on neurocognition and in that respect are more beneficial than typical antipsychotics. Recent studies, however, challenge this finding.

CONCLUSION

The reported positive, cognitive effects of atypical antipsychotics are slight, particularly compared to the severity of neurocognitive dysfunction found in schizophrenia. In clinical practice there seem to be no convincing reason for attaching much weight to any differential effects that typical or atypical antipsychotics may have on neurocognition.

[Parents with severe mental illness. Epidemiological data]

BACKGROUND

It is becoming increasingly clear that people with severe mental illness (SMI) are in need of support with parenting. So far, however, little is known about how many persons fall into this category.

AIM

To estimate how many SMI patients aged 18 to 65 are parents with children and how many need help with parenting.

METHOD

We based our estimate on epidemiological studies and on official records and data relating to SMI patients for the year 2009.

RESULTS

We estimated that 48% of patients with smi had children. The total number of such patients for the year 2009 was 68,000; this figure represents 0.9% of the Dutch population in the 18-64 age-group.

CONCLUSION

Health professionals and carers need to be alerted to the fact that almost 50%of the patients with SMI require possibly help in fulfilling their parental role. Potential problems in the parent-child relationship need to be registered in greater details so that more adequate care can be provided both at individual level and national level.

Treatment outcome in patients receiving assertive community treatment

In an observational study of severely mentally ill patients treated in assertive community treatment (ACT) teams, we investigated how treatment outcome was associated with demographic factors, clinical factors, and motivation for treatment. To determine psychosocial outcome, patients were routinely assessed using the Health of the Nation Outcome Scales (HoNOS). Trends over time were analyzed using a mixed model with repeated measures. The HoNOS total score was modeled as a function of treatment duration and patient-dependent covariates. Data comprised 637 assessments of 139 patients; mean duration of follow-up was 27.4 months (SD = 5.4). Substance abuse, higher age, problems with motivation, and lower educational level were associated with higher HoNOS total scores (i.e., worse outcome). To improve treatment outcome, we recommend better implementation of ACT, and also the implementation of additional programs targeting subgroups which seem to benefit less from ACT.

Validity of a short clinical interview for psychiatric diagnosis: the mini-SCAN

BACKGROUND

To promote clinical application of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) system a shorter version (the mini-SCAN) was devised. Its psychometric properties were unknown.

AIMS

To establish the validity and practical properties of the mini-SCAN.

METHOD

One hundred and six participants were interviewed twice, once with the SCAN and once with the mini-SCAN. The level of agreement was established for the categories: no disorder, affective disorders, anxiety disorders, non-affective psychotic disorders, affective psychotic disorders.

RESULTS

The mini-SCAN is a valid instrument. Most kappa values were around 0.90. Only for the class of affective psychotic disorders was the agreement moderate. Mean duration of the mini-SCAN interviews was 25 min shorter than the SCAN interviews. Participants and interviewers were generally satisfied with the interview format and questions.

CONCLUSIONS

The mini-SCAN can be used as a diagnostic instrument for clinical purposes and for clinical studies when the present episode is the focus of attention.

[Routine Outcome Monitoring for patients with severe mental illness: a consensus document]

BACKGROUND

Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI).

AIM

To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data.

METHOD

This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data.

RESULTS

Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied.

CONCLUSION

It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

What works for whom in a computer-mediated communication intervention in community psychiatry? Moderators of outcome in a cluster randomized trial

OBJECTIVE

An intervention to structure patient-key worker communication has been tested in a randomized controlled trial. The aim of this paper was to investigate effectiveness of the intervention in terms of moderators of effectiveness.

METHOD

A total of 507 patients with schizophrenia were included. Moderators of effectiveness were investigated using two-way anovas.

RESULTS

Patients with a better relationship with their key worker and a shorter duration of illness at baseline benefited more from the intervention in terms of quality of life. Patients who received the intervention who were in competitive employment or had a shorter duration of illness showed greater reduction of unmet needs. Older patients receiving the intervention had better treatment satisfaction.

CONCLUSION

Outcome of the intervention was moderated by patient characteristics. Moreover, the moderating characteristics varied depending on the specific outcome. Evidence on moderators is very limited, even though, they are significant for understanding, targeting and implementing complex interventions.

The effectiveness of peer support groups in psychosis: a randomized controlled trial

OBJECTIVE

To investigate the effect of a (minimally) guided peer support group (GPSG) for people with psychosis on social network, social support, self-efficacy, self-esteem, and quality of life, and to evaluate the intervention and its economic consequences.

METHOD

In a multi-center randomized controlled trial with 56 patients in the peer support group and 50 patients in the control condition, patients were assessed at baseline and after the last meeting at 8 months.

RESULTS

The experimental group showed GPSG to have a positive effect on social network and social support compared with the control condition. In the experimental condition, high attenders favored over low attenders on increased social support, self-efficacy, and quality of life. Economic evaluation demonstrated groups to be without financial consequences. The GPSG-intervention was positively evaluated.

CONCLUSION

Peer support groups are a useful intervention for people suffering from psychosis by improving their social network.

Cost-effectiveness of cognitive self-therapy in patients with depression and anxiety disorders

OBJECTIVE

Self-therapy interventions could potentially reduce healthcare expenses and the need for care in the treatment of depression and anxiety disorders. This study assessed the cost-effectiveness of cognitive self-therapy (CST) in patients with these disorders.

METHOD

A total of 151 patients were randomly assigned to CST or treatment as usual (TAU), and followed during 18 months. The Symptom Checklist 90 (SCL-90) was the primary outcome measure of the study. The reference year was 2003 (US$1.00 = euro 0.92).

RESULTS

Mean costs of patients in the CST group (US$4364) were lower than that of the patients who received TAU (US$5241). The results of the SCL-90 were slightly in favour of CST. Valuing an additional unit of health outcome at US$108 will lead to an 83% probability that CST is cost-effective.

CONCLUSION

Cognitive self-therapy appears to be cost-effective. Wider implementation of CST may relieve the burden of many patients with emotional disorders whose treatment needs cannot be met in current healthcare systems.

[The administrative incidence of non-affective psychoses in Friesland and Twente]

BACKGROUND

Research into the risk factors for schizophrenia has once again drawn attention to the geographical differences in the incidence and gender distribution of schizophrenia. The incidence - as recorded by the mental health care services - of non-affective psychotic disorders in the Netherlands is unknown.

AIM

To ascertain the mental-health-care recorded incidence of non-affective psychotic disorders in Friesland and Twente in 2002.

METHOD

The medical files of all adults who made their first contact with mental health care services in 2002 (n = 6,477) via two clinics in the Netherlands were screened for psychotic symptoms. All patients with psychotic symptoms (n = 242) were included and the clinical diagnosis was recorded. Thirty months later the most recent clinical diagnosis was recorded again. results Within six months of their first contact 75 patients were diagnosed with non-affective disorder. This diagnosis was still valid after 30 months. These results demonstrate an incidence of 2.2/10,000 inhabitants. The male-female ration was 1.8:1. The incidence of psychotic disorder did not differ significantly between the two regions under study.

CONCLUSION

The incidence found corresponds to the incidence reported in earlier Dutch studies; it lies on the 75th percentile of the cumulative incidence given in an international review.

Assertive community treatment in the Netherlands: a randomized controlled trial

OBJECTIVE

Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services.

METHOD

Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59).

PRIMARY OUTCOME

sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756.

RESULTS

Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found.

CONCLUSION

The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.

Economic consequences of alternative medication strategies in first episode non-affective psychosis

Background

Maintenance treatment appears to be successful in preventing relapses in first episode psychosis, but is also associated with side effects. Guided discontinuation strategy is a less intrusive intervention, but may lead to more relapses. In the current economic evaluation, costs and health outcomes of discontinuation strategy will be compared with the results of maintenance treatment in patients with remitted first episode psychosis.

Method

The study was designed as a randomised clinical trial. In total 128 patients were prospectively followed for 18 months after six months of stable remission. The economic evaluation was conducted from a societal perspective. Quality-adjusted life years (QALYs) were used as primary health outcome in the economic evaluation. Relapse rates were assessed in addition to various other secondary outcomes.

Results

There were no relevant differences in mean costs between groups during the study. Total costs were largely influenced by costs related to admissions to psychiatric hospitals. No differences between groups were found for QALY results.

Conclusions

There were no indications that either of the examined interventions is superior to the other in terms of costs or QALY results. Additional results indicated that the relapse rate in discontinuation strategy was twice as high, but without an increase in hospital admissions or negative consequences on other clinical outcomes. For a minority of remitted first episode patients, guided discontinuation strategy may offer a feasible alternative to maintenance treatment.

[Antipsychotics and sexual functioning in persons with psychoses]

BACKGROUND

So far little research has been done into sexual dysfunctions that develop during the use of antipsychotics. However, over the last 10 years a great deal of new and clinically useful information has become available.

AIM

To provide information about the frequency, nature and pathogenesis of sexual dysfunctions that arise during treatment with antipsychotics and to suggest some ways of tackling such problems in clinical practice.

RESULTS

In 30 to 60% of cases the use of antipsychotics is linked to sexual dysfunctions such as loss of libido, erectile and/or lubrication problems and orgasm and ejaculation disorders. If sexual dysfunctions are not actively addressed by clinicians they are likely to be underreported. The most frequent sexual dysfunctions are a result of treatment with antipsychotics with a high affinity for dopamine receptors and/or that cause a marked rise in the prolactin level. Antipsychotic-induced sexual dysfunctions are probably linked to a lower quality of life and lower treatment compliance. Possible mechanisms that underlie the influence of antipsychotics on sexual functioning are discussed. Also discussed are possible interventions designed to reduce sexual dysfunction.

CONCLUSIONS

During treatment with antipsychotics sexual dysfunctions occur frequently, depending on the type of antipsychotics prescribed. If clinicians actively address the problems of sexual dysfunction, they may often be able to arrive at a solution by giving information, by prescribing a different antipsychotic, by reducing the dose and/or by prescribing appropriate supplementary medication.

Needs of people with severe mental illness

OBJECTIVE

This study reviews conceptual and methodological issues of needs for care among people with severe mental illness (SMI) and presents data on their prevalence, correlates and consequences for mental health care.

METHOD

Focus is on the definition of the concept of need as what people can benefit from and its measurement by means of two instruments, the Needs for Care Assessment (NCA) and the Camberwell Assessment of Needs (CAN).

RESULTS

The prevalence of needs among patients with SMI varies between 4 and 10, which appears to be rather unrelated to gender, age or education, but not to severity of symptoms, diagnosis or treatment setting. Important is the perspective of the beholder: patient and professional differ significantly from each other in the assessment of number of needs and their adequate fulfillment. One of two to four needs are unmet, in particular in the area of psychological distress, daily activities, social contacts and psychotic symptoms. Prevalence of unmet needs seems to be related to the system of mental health care and to socioeconomic circumstances as well: the less integrated and continuous care and the poorer the life situation, the more unmet needs.

CONCLUSION

Unmet needs are a strong predictor of less favourable health perceptions and a lower quality of life. Needs are to a certain extent changeable, and thus amenable by treatment or mental health interventions. The prevalence of (un)met needs should be an outcome criterion for the evaluation of mental health service systems and for cross-cultural comparison.

Needs of people with severe mental illness

OBJECTIVE

This study reviews conceptual and methodological issues of needs for care among people with severe mental illness (SMI) and presents data on their prevalence, correlates and consequences for mental health care.

METHOD

Focus is on the definition of the concept of need as what people can benefit from and its measurement by means of two instruments, the Needs for Care Assessment (NCA) and the Camberwell Assessment of Needs (CAN).

RESULTS

The prevalence of needs among patients with SMI varies between 4 and 10, which appears to be rather unrelated to gender, age or education, but not to severity of symptoms, diagnosis or treatment setting. Important is the perspective of the beholder: patient and professional differ significantly from each other in the assessment of number of needs and their adequate fulfillment. One of two to four needs are unmet, in particular in the area of psychological distress, daily activities, social contacts and psychotic symptoms. Prevalence of unmet needs seems to be related to the system of mental health care and to socioeconomic circumstances as well: the less integrated and continuous care and the poorer the life situation, the more unmet needs.

CONCLUSION

Unmet needs are a strong predictor of less favourable health perceptions and a lower quality of life. Needs are to a certain extent changeable, and thus amenable by treatment or mental health interventions. The prevalence of (un)met needs should be an outcome criterion for the evaluation of mental health service systems and for cross-cultural comparison.

Treatment delay and response rate in first episode psychosis

OBJECTIVE

There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population.

METHOD

An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year.

RESULTS

The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response.

CONCLUSION

Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Multi-family treatment for patients with persistent auditory hallucinations and their relatives: a pilot study

OBJECTIVE

To test feasibility and effectiveness of multi-family treatment (MFT) for patients with persistent auditory hallucinations.

METHOD

A naturalistic pilot study with 6-month follow-up of 12 patients and 10 relatives. Pre- and post-treatment assessment concerned compliance, satisfaction, subjective burden, and control of voices, psychopathology, quality of life, social functioning and burden on the family.

RESULTS

Significant improvements were found in all domains. Compliance and satisfaction with treatment were satisfactory. Self-help contacts outside treatment sessions increased over time.

CONCLUSION

MFT may be considered a potentially effective form of additional treatment for refractory voice hearers.

Paraprofessionals for anxiety and depressive disorders

BACKGROUND

The established mental health care system does not have the resources to meet the extensive need for care of those with anxiety and depressive disorders. Paraprofessionals partially replacing professionals may be cost-effective.

OBJECTIVES

To investigate the effectiveness of any kind of psychological treatment for anxiety and depressive disorders performed by paraprofessionals compared with professionals, waiting list or placebo condition. To examine whether the results apply to clinically significant anxiety and depressive disorders of referred patients with a psychiatric history and/or whose illness has lasted two years or more.

SEARCH STRATEGY

CCDANCTR-Studies using the following terms: (paraprofessional* or para-professional* or non-professional* or non-professional* or peer or volunt*); EMBASE (ExerptaMedica), MEDLINE and PsycINFO, all years published, key words: para-/paraprofessional, non-/nonprofessional, rand*, respectively psy*; citation lists of articles reviewing the subject and included studies; correspondence with authors of controlled studies and review reports on the subject.

SELECTION CRITERIA

Randomised controlled trials that used symptom measures, and compared the effects of psychological treatments given by paraprofessionals (mental health care workers, paid or voluntary, unqualified with respect to the psychological treatment) with psychological treatments given by professionals, and with waiting list or placebo condition.

DATA COLLECTION AND ANALYSIS

The standard mean difference was used to pool continuous data from each trial, and odds ratios were used to pool dichotomous data, using a random effects model. The generic inverse variance method was used for combining continuous and dichotomous data. The effect of low quality studies and the use of self-rated versus observer-rated measures were tested, and subgroup analyses were performed for differences between depression and anxiety diagnosis, paraprofessionals with/without professional background, group/individual intervention, length of follow-up and gender (post-hoc subgroup analysis).

MAIN RESULTS

Five studies, all using self-report measures, reported five comparisons of paraprofessionals versus professionals (n=106) and five comparisons of paraprofessionals versus control condition (n=220). No differences were found between paraprofessionals and professionals (SMD=0.09, 95% CI -0.23 to 0.40, p=0.58; no significant heterogeneity). Studies comparing paraprofessionals versus control reported mixed continuous and dichotomous data showed a significant pooled effect in favour of paraprofessionals (OR=0.34, 95% CI 0.13 to 0.88, p=0.03), but heterogeneity was indicated (I(2)=60.9%, Chi(2)= 10.24, df=4, p=0.04). After correction for heterogeneity and removing one study of low quality, the pooling of data from three studies (n=128; mixed gender and women only) indicated no significant difference in effect between paraprofessionals and professionals (SMD=0.13, 95% CI -0.39 to 0.64; p=0.63) and a strongly significant pooled effect for three studies (n=188; women only) favouring paraprofessionals over the control condition (OR=0.30, 95% CI 0.18 to 0.48, p<0.00001), and homogeneity indicated between studies (I(2)=0%, Chi(2)=0.47, df=2, p=0.79).

AUTHORS' CONCLUSIONS

The few studies included in the review did not allow conclusions about the effect of paraprofessionals compared to professionals. Pooling data from three studies, involving women only, indicated a significant effect for paraprofessionals (all volunteers) compared to no treatment. The evidence to date may justify the development and evaluation of programs incorporating paraprofessionals in treatment programs for anxiety and depressive disorders.

Why is self-help neglected in the treatment of emotional disorders? A meta-analysis

BACKGROUND

Although the burden of emotional disorders is very high, mental health care is only available to a minority of patients. The literature suggests that self-help strategies, both bibliotherapy and self-help groups alike, are effective for various, less serious complaints but it is unclear whether available data support a role for self-help in treatment protocols for patients with clinically significant emotional disorders.

METHOD

We searched the literature with a focus on 'anxiety' and/or 'depressive disorder'. Standardized assessment of diagnosis or symptoms and randomized controlled trials were inclusion criteria for a meta-analysis.

RESULTS

The mean effect size of self-help (mainly bibliotherapy) v. control conditions is 0.84, and 0.76 for follow-up; the effect sizes of self-help v. treatment are -0.03 and -0.07 respectively. A longer treatment period is more effective.

CONCLUSIONS

Bibliotherapy for clinically significant emotional disorders is more effective than waiting list or no treatment conditions. The dearth of studies on self-help groups for emotional disorders does not permit an evidence-based conclusion concerning the effects of self-help groups. No difference was found between bibliotherapy and psychiatric treatment of relatively short duration.

Hallucination focused integrative treatment improves quality of life in schizophrenia patients

OBJECTIVE

Psychosocial treatment seems to be effective in the management of schizophrenia, although less in the area of quality of life and social functioning. To study the effectiveness of a hallucination focused integrated treatment with cognitive-behaviour therapy and coping training among schizophrenia patients suffering from 'hearing voices'.

METHOD

In a randomized controlled trial (RCT) with 31 patients in the integrated treatment condition and 32 patients in the routine care condition, quality of life was assessed with the self-report questionnaire of the WHO (Bref), and social role functioning with an interviewer based schedule, at entry and 9 (post-treatment) and 18 months later.

RESULTS

Follow-up data suggest a significant improvement of quality of life and in particular in social role functioning (effect size 0.64) in favour of the integrated treatment.

CONCLUSION

The integrated treatment seems to be effective in reducing overall disability levels and number of patients with serious disabilities.

Cost-effectiveness of the HIT programme in patients with schizophrenia and persistent auditory hallucinations

OBJECTIVE

To examine the cost-effectiveness of Hallucination focused Integrative Treatment (HIT) in patients with schizophrenia and a history of persistent auditory hallucinations.

METHOD

Costs, in and outside the health care sector, and outcomes were registered prospectively during a period of 18 months for patients who received the HIT programme and for patients in the care as usual (CAU) condition. The Positive and Negative Syndrome Scale (PANSS) was used as main outcome measure in the cost-effectiveness analysis. Bootstrap analyses provided additional information on the skewly distributed costs.

RESULTS

Mean costs per patient in the HIT group (18,237 dollars) were lower than the mean costs per patient in the CAU group (21,436 dollars). Results of the PANSS were slightly in favour of the HIT group.

CONCLUSION

There appears to be no significant cost-effectiveness advantage of the HIT programme over CAU. Additional analyses indicated that future application of the HIT programme will, in most cases, lead to a reduction of (non) medical costs.

Near-field measurement of short-range correlation in optical waves transmitted through random media

Two-dimensional near-field images of speckle patterns formed by optical waves transmitted through a disordered porous silica glass sample are measured. The corresponding 2D intensity correlation function, C, is extracted. The subwavelength spatial resolution of near-field microscopy allows us to resolve in the spatial distribution of C the expected subwavelength oscillations and to follow their dependence on the excitation wavelength. Finally, we deduce the effective refractive index of the material by fitting the theoretical spatial dependence of C to our experimental results.

Day hospital versus admission for acute psychiatric disorders

BACKGROUND

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVES

To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), PsycLIT (1966 to December 2000), and the reference lists of articles. We approached trialists to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. Individual patient data were therefore sought so that outcomes could be reanalysed in a common format.

MAIN RESULTS

Nine trials (involving 1568 people) met the inclusion criteria. Individual patient data were obtained for four trials (involving 594 people). Combined data suggested that, at the most pessimistic estimate, day hospital treatment was feasible for 23% (n=2268, CI 21 to 25) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in number of days in hospital between day hospital patients and controls (n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55). However, compared to controls, people randomised to day hospital care spent significantly more days in day hospital care (n=265, 3 RCTs, WMD 2.34 days/month CI 1.97 to 2.70) and significantly fewer days in inpatient care (n=265, 3 RCTs, WMD -2.75 days/month CI -3.63 to -1.87). There was no significant difference in readmission rates between day hospital patients and controls (n=667, 5 RCTs, RR 0.91 CI 0.72 to 1.15). For patients judged suitable for day hospital care, individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n=407, Chi-squared 9.66, p=0.002), but not social functioning (n=295, Chi-squared 0.006, p=0.941) amongst patients treated in the day hospital. Four of five trials found that day hospital care was cheaper than inpatient care (with cost reductions ranging from 20.9 to 36.9%).

REVIEWER'S CONCLUSIONS

Caring for people in acute day hospitals can achieve substantial reductions in the numbers of people needing inpatient care, whilst improving patient outcome.

Costs of deinstitutionalization in a rural catchment area in The Netherlands

BACKGROUND

In contrast to many other countries, The Netherlands left the initiative in deinstitutionalizing mental health care to the traditional providers of mental health services. The goal of this study is to determine the effect of this policy on the allocation of mental health care resources to services.

METHOD

All 20- to 64-year old users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Service utilization was combined with the direct unit costs of these services for the 1999 price level. Changes in the population as to size and age were taken into account.

RESULTS

In 1999 the direct costs of mental health care were Euro 268 per adult inhabitant of the register area, which is 9% higher than in 1990. Costs increased most in the early 1990s before deinstitutionalization policy took effect. From 1993 and onwards the reduced length of stay in the hospital was the main cause for the decreased costs of in-patient care. These savings equalled the increased expenditures for day-treatment, sheltered residences and home-treatment, even though the unit costs of these types of community care are much lower than the unit costs of admissions. This was not caused by an increasing number of new clients, but was a result of longer periods of care during a larger number of years.

CONCLUSIONS

These findings are in accordance with Dutch mental health care policy, which aims at prolonged care and aftercare outside the hospital whenever possible.

[Care requirements for chronic psychiatric patients in general practice: shared responsibility with mental health professionals]

Every year in the Netherlands, at least 41,000 patients in mental health care suffer from long-lasting (> 2 years) psychiatric problems such as psychoses, affective disorders, anxiety disorders or personality disorders. A representative survey reveals that during certain periods of time about 20% of them only receive care from their general practitioner. The general practitioner has to deal with the many and complex needs of care in the areas of, for example, psychological complaints, psychotic symptoms, social contacts and information about treatment. According to the patient, one in four of these needs are unmet, resulting in a reduced quality of life. This situation calls for a pro-active attitude on the part of the general practitioner who should nevertheless leave the key role in managing the care of these patients to the mental health professionals.

Are needs and satisfaction of care associated with quality of life? An epidemiological survey among the severely mentally ill in the Netherlands

Is the quality of life of severe mentally ill patients influenced by the intensity of the care provided, their satisfaction with services and/or the amount of unmet needs? The interrelatedness of these three outcome measures was investigated in a sample of 101 patients dependent on long-term psychiatric care in the Northeast of the Netherlands. Instruments used were the Camberwell Assessment of Needs, the Verona Service Satisfaction Schedule and a health related quality of life instrument, the EuroQoL. Quality of life was unrelated to satisfaction with services but was strongly associated with unmet needs in the area of mental and physical health, and of rehabilitation. Quality of life decreased as needs increased. Needs were also strongly related to diagnosis and cognitive functioning. Furthermore, more intensive care settings were provided as needs increased. Demographic, diagnostic and treatment variables did not explain much extra variance in quality of life. Despite the availability of various services in the region there was a lack of tailor made care which took into account specific unmet needs with regard to information, social contacts, and daily activities.

Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care

***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS***

BACKGROUND

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVE

The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders.

METHODS - STUDY SELECTION

Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format.

RESULTS

Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%).

CONCLUSIONS

Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS***

BACKGROUND

People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective.

OBJECTIVES

The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions).

METHODS - STUDY SELECTION

Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score.

RESULTS

Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT.

CONCLUSIONS

The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS***

BACKGROUND

This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic.

OBJECTIVES

There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders.

METHODS - STUDY SELECTION

Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data.

RESULTS

There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs. (ABSTRACT TRUNCATED)

Deinstitutionalisation in the Netherlands

In the Netherlands mental hospitals and psychiatric departments in general hospitals kept the initiative in implementing community-based replacements for inpatient care. The goal of this study is to determine to what extent day treatment, sheltered residences and assertive home treatment were effective alternatives, rather than additions to inpatient care. All adult users and their use of intensive community- and hospital-based services between 1989 and 1997 were retrieved from the Groningen case register. Statistics about changes in the use of mental health care provisions were corrected for changes in the population as to size and age. The number of patients in day treatment, sheltered residences and in particular home treatment grew between 1989 and 1997 to a large degree, as did their average use of these services. In that same period inpatient care lost some, though not many patients, but the average length of their stay in the hospital was reduced by 33%. Analysis of treated incidence and prevalence showed that the implementation of alternatives to hospital-based care did not attract new patients but kept patients longer in mental health care.

Recovery from psychotic illness: a 15- and 25-year international follow-up study

BACKGROUND

Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia.

AIMS

To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables.

METHODS

Historic prospective study. Standardised assessments of course and outcome.

RESULTS

About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery.

CONCLUSIONS

A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.