Seroprevalence of Mycoplasma bovis in bulk milk samples in Irish dairy herds and risk factors associated with herd seropositive status

Mycoplasma bovis is a serious disease of cattle worldwide; mastitis, pneumonia, and arthritis are particularly important clinical presentations in dairy herds. Mycoplasma bovis was first identified in Ireland in 1994, and the reporting of Mycoplasma-associated disease has substantially increased over the last 5 years. Despite the presumed endemic nature of M. bovis in Ireland, there is a paucity of data on the prevalence of infection, and the effect of this disease on the dairy industry. The aim of this observational study was to estimate apparent herd prevalence for M. bovis in Irish dairy herds using routinely collected bulk milk surveillance samples and to assess risk factors for herd seropositivity. In autumn 2018, 1,500 herds out of the 16,858 herds that submitted bulk tank milk (BTM) samples to the Department of Agriculture testing laboratory for routine surveillance were randomly selected for further testing. A final data set of 1,313 sampled herds with a BTM ELISA result were used for the analysis. Testing was conducted using an indirect ELISA kit (ID Screen Mycoplasma bovis). Herd-level risk factors were used as explanatory variables to determine potential risk factors associated with positive herd status (reflecting past or current exposure to M. bovis). A total of 588 of the 1,313 BTM samples were positive to M. bovis, providing an apparent herd prevalence of 0.45 (95% CI: 0.42, 0.47) in Irish dairy herds in autumn 2018. Multivariable analysis was conducted using logistic regression. The final model identified herd size, the number of neighboring farms, in-degree and county as statistically significant risk factors for herd BTM seropositivity to M. bovis. The results suggest a high apparent herd prevalence of seropositivity to M. bovis, and evidence that M. bovis infection is now endemic in the Irish dairy sector. In addition, risk factors identified are closely aligned to what we would expect of an infectious disease. Awareness raising and education about this important disease is warranted given the widespread nature of exposure and likely infection in Irish herds. Further work on the validation of diagnostic tests for herd-level diagnosis should be undertaken as a matter of priority.

Is moving from targeted culling to BCG-vaccination of badgers (Meles meles) associated with an unacceptable increased incidence of cattle herd tuberculosis in the Republic of Ireland? A practical non-inferiority wildlife intervention study in the Republic of Ireland (2011-2017)

Bovine tuberculosis (BTB) remains as a costly disease of cattle-herds in the Republic of Ireland (ROI). This persistence is partially attributable to the presence of M. bovis infection in a wildlife reservoir, the European badger (Meles meles). Thus, both area-wide and limited-area targeted-badger-culling have been part of the ROI-BTB control/eradication program to help reduce the future incidence of a cattle-herd BTB breakdown (i.e. a "new herd-level occurrence of BTB"). However, neither badger-culling practice can be sustained as a major component in the ongoing BTB eradication program in the ROI. Vaccination of badgers with Bacille Calmette-Guérin (BCG) has been proposed as an alternative to badger culling. Thus, in 2011, a five-year non-inferiority study was implemented in seven counties in the ROI. This study was designed to compare and contrast the cattle-herd-BTB-incidence in areas where intramuscular badger vaccination would be implemented versus the cattle-herd-BTB-incidence in the remaining area of the same county where targeted-badger-culling was maintained as the standard treatment response to probable badger-sourced BTB breakdowns. Our outcome of interest was a new cattle-herd-BTB-episode (breakdown) with a total of >2 standard skin-test (SICTT) reactors detected during the episode. Treatments (badger vaccination or targeted badger culling) were cluster allocated based on where the majority of the herd owner's land was located. To assess the impact of the two treatments, we compared the incidence-risk, of our defined outcome, for cattle herds in the area under vaccination to the outcome incidence-risk for cattle herds in the remainder of the same county after 4 and 5 years of having implemented badger vaccination. A random-effects logit model with adjustment for clustering by treatment, and statistical control of herd-type, herd-size and five-year prior-BTB-episode history was used for our analyses. Although not included in the logistic model, a relative badger density metric based on the annual number of badgers captured-per-sett-night of capturing effort was developed for each treatment area; this metric indicated that relative badger density was approximately 40 % higher in vaccination areas than in the targeted badger-culling areas during our study. Overall, our study results indicated that vaccination was not inferior to targeted badger-culling in four counties and badger vaccination was deemed to produce ambivalent results in one (County Cork North) of the seven study sites in the ROI. A post-study investigation, in County Galway, where vaccination was deemed inferior to target culling, revealed that widespread purchases of cattle from a nearby cattle mart, by herd owners in the vaccination-area, was associated with the increased herd and vaccination-area risk of BTB. No single "biasing hypothesis" was evident for the apparent vaccine inferiority in the second study site (County Monaghan) where vaccination was deemed inferior to targeted culling; hence no further investigations were conducted.

Eradicating BVD, reviewing Irish programme data and model predictions to support prospective decision making

Bovine Viral Diarrhoea is an infectious production disease of major importance in many cattle sectors of the world. The infection is predominantly transmitted by animal contact. Postnatal infections are transient, leading to immunologically protected cattle. However, for a certain window of pregnancy, in utero infection of the foetus results in persistently infected (PI) calves being the major risk of BVD spread, but also an efficient target for controlling the infection. There are two acknowledged strategies to identify PI animals for removal: tissue tag testing (direct; also known as the Swiss model) and serological screening (indirect by interpreting the serological status of the herd; the Scandinavian model). Both strategies are effective in reducing PI prevalence and herd incidence. During the first four years of the Irish national BVD eradication programme (2013-16), it has been mandatory for all newborn calves to be tested using tissue tag testing. During this period, PI incidence has substantially declined. In recent times, there has been interest among stakeholders in a change to an indirect testing strategy, with potential benefit to the overall programme, particularly with respect to cost to farmers. Advice was sought on the usefulness of implementing the necessary changes. Here we review available data from the national eradication programme and strategy performance predictions from an expert system model to quantify expected benefits of the strategy change from strategic, budgetary and implementation points of view. Key findings from our work include (i) drawbacks associated with changes to programme implementation, in particular the loss of epidemiological information to allow real-time monitoring of eradication progress or to reliably predict time to eradication, (ii) the fact that only 25% of the herds in the Irish cattle sector (14% beef, 78% dairy herds) would benefit financially from a change to serosurveillance, with half of these participants benefiting by less than EUR 75 per annum at herd level or an average of EUR 1.22 per cow, and (iii) opportunities to enhance the effectiveness of the current programme, particularly in terms of time to eradication, through enforced compliance with PI removal as currently outlined in programme recommendations. The assembled information provides scientific arguments, contributing to an informed debate of the pros and cons of a change in eradication strategy in Ireland.

Temporal trends in the retention of BVD+ calves and associated animal and herd-level risk factors during the compulsory eradication programme in Ireland

The national BVD eradication programme in Ireland started on a voluntary basis in 2012, becoming compulsory in 2013. The programme relies on accurate identification and prompt removal of BVD+ calves. However, a minority of herd owners have chosen to retain BVD+ animals (defined as still being alive more than seven weeks after the date of the initial test), typically with a view to fattening them to obtain some salvage value. During each year of the programme, additional measures have been introduced and implemented to encourage prompt removal of BVD+ animals. The objective of this study was to describe temporal trends in the retention of BVD+ calves and associated animal and herd-level risk factors during the first three years of the compulsory eradication programme in Ireland. The study population included all BVD+ calves born in Ireland in 2013-2015. A parametric survival model was developed to model the time from the initial BVD test until the animal was slaughtered/died on farm or until 31 December 2015 (whichever was earlier). A total of 29,504 BVD+ animals, from 13,917 herds, were included in the study. The proportion of BVD+ animals that were removed from the herd within 7 weeks of the initial test date increased from 43.7% in 2013 to 70.3% in 2015. BVD+ animals born in 2015 had a much lower survival time (median=33days) compared to the 2013 birth cohort (median=62days), with a year on year reduction in survival of BVD+ calves. In the initial parametric survival models, all interactions with herd type were significant. Therefore, separate models were developed for beef and dairy herds. Overall the results of the survival models were similar, with birth year, BVD+ status, herd size, county of birth and birth month consistently identified as risk factors independent of herd type (beef or dairy) or the numbers of BVD+ animals (single or multiple) in the herd. In addition, the presence of a registered mobile telephone number was identified as a risk factor in all models except for dairy herds with a single BVD+, while the sex of the BVD+ calf was only identified as a risk factor in this model. Significant progress has been made in addressing the issue of retention of BVD+ calves, however, there is a need for further improvement. A number of risk factors associated with retention have been identified suggesting areas where future efforts can be addressed.

Prevalence and distribution of exposure to Schmallenberg virus in Irish cattle during October 2012 to November 2013

Background

Schmallenberg virus (SBV) was first identified in November 2011. It is a novel Orthobunyavirus (family Bunyaviridae) whose main ill effect is congenital malformation of the musculoskeletal and central nervous systems. It is borne by Culicoides spp., and has spread extensively in western Europe. The first case of SBV in Ireland was diagnosed in October 2012. It was anticipated that once the virus emerged in Ireland that there would be wide scale or nationwide spread over the course of the 2013 vector season. The objectives of this study were to determine the seroprevalence and distribution of exposure to Schmallenberg virus in Irish cattle from November 2012 to November 2013.

Methods

Samples of brain for the pathology based surveillance were collected from malformed bovine and ovine foetuses submitted for post mortem examination. These samples were tested for SBV using RT-qPCR. Three serological surveys were carried out on sera submitted for the national brucellosis eradicartion programme. A spatial analysis of both sets of data was carried out.

Results

Between October 2012 and 10th May 2013, SBV was confirmed by RT-qPCR in brain tissues from malformed foetuses obtained from 49 cattle herds and 30 sheep flocks in Ireland. In national serosurveys conducted between November 2012 until November 2013 the herd-level and animal-level SBV seroprevalences in cattle were 53 and 36 % respectively for the first survey, 51 and 35 % for the second survey and 53 and 33 % for the third survey. The herd level seroprevalence in counties ranged from 0 to 100 %, with the counties in the south and southeast having the highest seroprevalence (>50 %), the midlands a moderate herd level seroprevalence (10–50 %) while northern and north western counties had a low herd level seroprevalence (0–10 %). There was close spatial agreement between the results of the two different targeted surveillance strategies.

Conclusions

At the end of the 2012 vector season, there was widespread exposure to SBV among herds in southern and south eastern Ireland. During 2013, there was little or no evidence of further outward spread, unlike the situation in several other European countries. Given the lack of evidence for circulation of the virus since 2012, it is likely that the younger age cohort in herds previously exposed to SBV and substantial proportions of animals of all ages on the margins of affected areas are immunologically naïve to SBV, and would be susceptible to infection if the virus were to re-emerge.

Tuberculosis in cattle herds are sentinels for Mycobacterium bovis infection in European badgers (Meles meles): the Irish Greenfield Study

In Ireland badgers are removed in response to tuberculosis (TB) breakdowns in cattle herds (focal culling). Prevalence studies, conducted using a detailed post mortem and bacteriological examination, showed that 36-50% of badgers were infected with Mycobacterium bovis. Focal culling forms part of the medium term national strategy for the control of bovine TB in cattle and is based on the premise that badgers in areas with herd breakdowns have a higher prevalence of infection than the badger population at large. However, the hypothesis that cattle can be used as sentinels for infection in the badger population has never been formally tested. In this study we tested the hypothesis by determining the infection prevalence in badgers in areas where there had been historically, a consistently low prevalence of infection in cattle. Low cattle TB prevalence areas were defined as those herds with ≤ 2 standard reactors in the annual round of skin testing over the preceding 5 years (Greenfield sites). Using GIS, and adjusting for variation in land use, previous culling and cattle density, 198 Greenfield sites were identified and surveyed, and 138 areas with badger setts or signs of badger activity were identified. A single badger was removed from 87 sites and all were examined using detailed post mortem and bacteriological procedures. A prevalence of M. bovis infection of 14.9% was found in the Greenfield site badgers. This prevalence was significantly lower (P<0.001) than in badgers removed during focal culling (36.6%). The results validate the use of cattle as sentinels for TB in badgers and support the medium term national strategy for the control of bovine TB. The geographic variation in M. bovis infection prevalence in the Irish badger populations will be used when devising strategies for the incorporation of badger vaccination into the long term bovine TB control programme.

An all-island approach to mapping bovine tuberculosis in Ireland

This study used techniques in Geographical Information Systems (GIS) to explore the spatial patterns of bovine tuberculosis (TB) in the whole island of Ireland over an 11-year period. This is the first time that data pertaining to TB from the Republic of Ireland and Northern Ireland have been collated and examined in an all-Ireland context. The analyses were based on 198, 156 point locations representing active farms with cattle in Northern Ireland and the Republic of Ireland between the years 1996 and 2006. The results consist of a series of maps giving a visual representation of cattle populations and associated detected bTB levels on the island of Ireland over this time interval.

Survival and dispersal of a defined cohort of Irish cattle

An understanding of livestock movement is critical to effective disease prevention, control and prediction. However, livestock movement in Ireland has not yet been quantified. This study has sought to define the survival and dispersal of a defined cohort of cattle born in Co. Kerry during 2000. The cohort was observed for a maximum of four years, from January 1, 2000 to December 31, 2004. Beef and dairy animals moved an average 1.31 and 0.83 times, respectively. At study end, 18.8% of the beef animals remained alive on Irish farms, including 6.7% at the farm-of-birth, compared with 48.6% and 27.7% for dairy animals respectively. Beef animals werae dispersed to all Irish counties, but mainly to Cork, Limerick, Tipperary and Galway. Dairy animals mainly moved to Cork, Limerick, and Tipperary, with less animals going to Galway, Meath and Kilkenny. The four-year survival probability was 0.07 (male beef animals), 0.25 (male dairy), 0.38 (female beef), and 0.72 (female dairy). Although there was considerable dispersal, the number of moves per animal was less than expected.

Risk factors for disclosure of additional tuberculous cattle in attested-clear herds that had one animal with a confirmed lesion of tuberculosis at slaughter during 2003 in Ireland

All the Irish cattle herds considered "clear" of bovine tuberculosis (BTB) having a single animal with a tuberculous lesion at slaughter during 2003 were identified. We performed a descriptive and logistic regression analysis to investigate whether selected risk factors had an association with the result of the herd test immediately after the tuberculous lesion was found ("Factory Lesion Test", FLT). At the FLT, only 19.7% (n=338) of these 1713 herds had 1 or more standard reactors. The lesioned animal was home-bred in 46% of the "source" herds; these herds had an increased risk (23.4%) of having at least 1 standard reactor animal relative to herds with a purchased-lesioned animal (16.6%) (RR=1.41). Our logistic models identified a number of important risk factors; two that appeared most important in predicting the FLT outcome were the time spent (residency) by the lesioned animal in the "source" herd, and the presence, or not, of the lesioned animal in a previous BTB episode in either the "source" herd, or the seller's herd in the case the lesioned animal was purchased. Our models fit the data well based on the Hosmer-Lemeshow test, however their sensitivity and specificity were very low (57% and 61% respectively). Surveillance of the cattle population for BTB using lesions found at slaughter is an essential component of an overall control program. Nonetheless, due to the poor predictability of the variables we measured, complete herd investigations are needed to help explain the FLT outcome of a herd.

Does reactive badger culling lead to an increase in tuberculosis in cattle?

The conclusion from the randomised badger culling trial was that localised badger culling not only fails to control but can actually increase the incidence of bovine tuberculosis in cattle. Professor Simon More and colleagues from University College Dublin question that conclusion, arguing that the data do not provide sufficient evidence to rule out alternative hypotheses.

Genotyping of Mycobacterium bovis isolates from badgers in four areas of the Republic of Ireland by restriction fragment length polymorphism analysis

An analysis of the molecular epidemiology of Mycobacterium bovis in badgers was made in four selected areas of the Republic of Ireland in which an intensive badger removal programme was being carried out over a period of five years. Tissue samples from 2310 badgers were cultured. Restriction fragment length polymorphism (RFLP) analysis with IS6110, polymorphic GC-rich sequence (PGRS) and direct repeat sequence (DR) probes was applied to the isolates from 398 badgers, and 52 different rflp types were identified. Most of the isolates belonged to seven predominant types, and the other 45 types were represented by few isolates. An analysis suggests that some of these 45 types may have been introduced by the inward migration of badgers and others may have been the result of genetic changes to one of the prevalent types. The badgers were divided into groups on the basis of the sett at which they were captured, and RFLP typing was applied to isolates from two or more badgers from 85 groups. Multiple RFLP types were identified among isolates from 50 of these groups, suggesting that badgers probably moved frequently between group territories.

Quantifying badger exposure and the risk of bovine tuberculosis for cattle herds in county Kilkenny, Ireland

The objectives of the study were to quantify the levels of badger exposure for cattle and to test the hypothesis that increased badger exposure does not increase the risk of bovine tuberculosis (BTB) in a herd. Information that became available from the targeted removal of badgers over the study period, and from a badger-removal project in county Kilkenny, during 1996-1999 was used. The specific location of cattle within each farm, and the length of time that cattle spent in each farm field during the grazing season, and in the barnyard during winter, was used to build an exposure coefficient to quantify the amount of badger exposure that cattle encountered either on pasture or in the barn. The study design was a matched case-control study in which the control herds were selected using incidence density sampling. During the 4-year study period, 543 badgers were removed and of these 96 badgers were classified as tuberculosis positive; 96 BTB herd breakdowns occurred. There was a significant association between case herds and having a higher badger sett exposure coefficient during 1996-1998. No significant association between case herds and having a higher exposure coefficient based on the number of badgers, or the number of tuberculous badgers, during September 1997-December 1999 was found.

Spatial relationship between Mycobacterium bovis strains in cattle and badgers in four areas in Ireland

We investigated whether strains (restriction fragment length polymorphism, RFLP-types) of Mycobacterium bovis isolated from badgers and from cattle clustered among and within four areas in Ireland. The spatial scan test and nearest-neighbor analysis were used as the spatial cluster-detection techniques. In addition, for each of the major strains, associations between the distance to badger setts and the "centroid" of the cattle farm were assessed in a logistic model. Overall, between September 1997 and May 2000, 316 and 287 M. bovis samples, from badgers and cattle, respectively, were strain-typed. The distribution of strains in badgers, and separately in cattle, differed among areas. Within each of the four large areas, badgers and cattle tended to have similar strains; this is consistent with the sharing of M. bovis strains within an area. In more detailed within-area analyses, some spatial clusters of M. bovis strains were detected, separately, in both cattle and badgers. Almost half of the infected badger setts with a specific strain were located outside of the "detected" clusters. There was no association between the number of infected badgers with a specific M. bovis strain within 2 or 5 km distances to cattle herds, and the risk of the same strain in cattle. We speculate about the dynamic nature of badger movements, as an explanation for the absence of more clusters of most of the strains of M. bovis isolated from badgers, and its impact on trying to study transmission of M. bovis between cattle and badger.

Bovine tuberculosis in badgers in four areas in Ireland: does tuberculosis cluster?

We described the distribution of badger populations in four different areas in the Republic of Ireland. The data came from periodic targeted badger-removal and subsequent post-mortem examinations conducted between 1989 and September 1997, and from a formal badger-removal project in the same areas from 1997 through 1999. Records were complete for 2292 badgers regarding the date of capture, tuberculosis status, geographical area and specific sett from where the badgers were snared. Of 3187 setts, 2290 had no badgers recorded against them (i.e. were inactive). The badger-level prevalence of tuberculosis differed among areas (range 13-29%). Badger populations were highly clustered by sett, and this result was similar over the four study areas. The median number of badgers per active sett was 2. Tuberculous badgers also clustered within a sett. The third quartile of tuberculous badgers was 1 per active sett. The prevalence of tuberculous badgers within a sett was not related to the total number of badgers. There was little evidence of spatial clustering with only one local cluster of tuberculous setts in each of three areas, and none in the fourth area. After adjusting for the number of badgers per sett, only one area had spatial clusters identified.

Irish soil and land-use classifications as predictors of numbers of badgers and badger setts

This study investigated possible associations between soil types, land use and badger numbers in an area of the Irish Midlands where badger removal had been conducted during 1989-1994. For this purpose, the area was divided into approximately 2500 geo-referenced square grids of 0.5 degrees km per side. For the outcomes (setts per grid, badgers per grid and tuberculous badgers per grid), Poisson models of land use, of soil type, and a combination of these two were developed. Influential grids were removed and the models adjusted for over-dispersion in the badger outcomes. Mineral-based soils, dry and very-dry peat soils supported increased numbers of setts and badgers. High-quality pasture was the major land use (pastures often are found on mineral-based soils) and supported increased numbers of setts, badgers, and tuberculous badgers. "Natural" areas also supported more setts and broad-leaf forested areas were associated with increased tuberculous badger numbers. Discontinuous urban areas tended to decrease sett numbers per grid. Hedgerow length was not an important predictor given the information on soil type and land use. Spatial correlations existed for badger setts in 1 degrees km grids, for badger numbers in 1.5 degrees km grids, and for tuberculous badgers in 2 degrees km grids. The latter two grids have approximately the same area as the territory size used by a social group of badgers. There were no spatial correlations at the smallest (0.5 km) grid size.

Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Measurement and psychotherapy. Evidence-based practice and practice-based evidence

BACKGROUND

Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice.

AIMS

To review the developments in measurement relevant to psychotherapy.

METHOD

Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skillfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement.

RESULTS

Modern methods of measurement can support 'evidence-based practice' for psychological treatments. They also support 'practice-based evidence', a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs).

CONCLUSIONS

Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.

Does a visual perceptual disturbance characterize trauma-related anxiety syndromes?

The i-test was developed to assess the visual-perceptual disturbances (VPDs) frequently reported by anxious patients. Persons with the disturbance report a specific abnormal illusion of movement when they maintain a fixed gaze at the i-test stimulus. Base rates for positive responses to the i-test and for reports of a "recurrent specific memory" (RSM) of a fear experience were obtained in psychiatric outpatient (n = 301) and community (n = 128) samples. In each case, approximately one fifth of participants had a positive response to the i-test and one fifth of participants reported an RSM of fear. A positive response to the i-test is observed in women more frequently than in men. Among psychiatric patients, approximately 90% of patients who report one symptom also report the other symptom; among community members, the concordance rate is approximately 33%. When psychiatric patients with both an abnormal illusion of movement response and an RSM of trauma are treated with eye movement desensitization, both symptoms are removed in 70% of cases; when these patients undergo some other form of treatment, both symptoms are removed in 30% of cases. These results indicate that the i-test is an effective way of identifying VPDs associated with psychopathologic conditions; the association between the abnormal illusion of movement and reports of recurrent specific memories of fear experiences suggests that the VPD may be a marker of traumatic stress syndromes.

Cost-effectiveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services

BACKGROUND

It is known that a small number of patients with mental health problems have chronic disorders and account for a disproportionate amount of mental health costs. This randomized controlled trial evaluated the cost-effectiveness of psychodynamic-interpersonal therapy vs treatment as usual in patients with mental health problems who were unresponsive to usual treatment.

METHOD

Subjects (N = 110) with nonpsychotic disorders unresponsive to 6 months of routine specialist mental health treatment were enrolled in a randomized controlled trial. Sixty-three percent were women, the mean age was 41.4 years, the median duration of illness was 5 years, 68% were unemployed or receiving state benefits because of illness, and 75.5% had a depressive illness. Intervention patients received 8 weekly sessions of psychodynamic-interpersonal psychotherapy. Control patients received usual care from their psychiatrist. Outcome measures included ratings of psychological distress and health status and a detailed economic evaluation. Analysis was conducted on an intent-to-treat basis.

RESULTS

Subjects randomized to psychotherapy had a significantly greater improvement than controls in psychological distress and social functioning 6 months after the trial. Baseline treatment costs were similar for both groups. Subjects who received psychotherapy showed significant reductions in the cost of health care utilization in the 6 months after treatment compared with controls. The extra cost of psychotherapy was recouped within 6 months through reductions in health care use.

CONCLUSION

These preliminary findings suggest that brief psychodynamic-interpersonal therapy may be cost-effective relative to usual care for patients with enduring nonpsychotic symptoms who are not helped by conventional psychiatric treatment.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

Large-volume sample stacking of selected drugs of forensic significance by capillary electrophoresis

Large-volume sample stacking capillary electrophoresis (LVSS-CE) and conventional capillary electrophoresis (CE) are compared for the separation of drugs of significance to forensic and clinical analyses. LVSS-CE for cations requires the use of an electroosmotic flow (EOF) modifier in conjunction with polarity switching to effect on-column concentration of an analyte and its subsequent migration in the capillary. The run buffer consists of 0.05 mol dm(-3) disodium tetraborate adjusted to pH 2.2 with orthophosphoric acid, and the EOF modifier is 0.002 mol dm(-3) cetyltrimethylammonium bromide. CE investigations used an identical run buffer minus the EOF modifier. LVSS-CE and CE investigations used injection times of 30 s and 3 s, respectively. Both modes of capillary electrophoresis are compared in terms of their limits of detection, efficiency, resolution and reproducibility. LVSS-CE is also applied to the analysis of a spiked urine sample.

Improving the skills of established general practitioners: the long-term benefits of group teaching

This study set out to determine the long-term benefits of teaching psychiatric interview skills. Nine established general practitioners, eight of whom were also trainers, took part some 18 months after attending a problem-based interviewing course. Interview skills were assessed by rating behaviour during 10-minute videorecorded simulated consultations with role-players, recorded before and after training and at follow-up. The finding of an earlier study that, in terms of the course model, training successfully modified the doctor's behaviour, was largely replicated. In addition, not only were acquired skills maintained but further change took place during the follow-up period, change that can be seen as improvement in terms of the course model.

Psychotherapy and general practice

The authors review the development of liaison psychotherapy in general practice, and argue that a 'skill-sharing' approach, where the general practitioner retains the treatment role, is a more efficient model than a 'consultation' approach. Skill-sharing models are reviewed, and the need for psychiatrists and psychotherapists to be more directly involved in teaching basic psychotherapeutic skills to general practitioners is emphasised.

Psychiatric day hospitals--another route to institutionalization?

Nineteen long-stay day patients were referred to a rehabilitation team and their outcome after a year is compared with 19 day patients who were not referred, but were matched for age, sex and diagnosis. Seven rehabilitation team patients had been discharged at 12 months as against 3 of the non-rehabilitation patients, but this was not a significant difference. Discharged patients were less disturbed at the beginning of the study and had fewer negative symptoms throughout. Discharge did not reduce the frequency of social contact. There was a suggestion that morale was sustained better in the rehabilitation patient and in their nurses. We conclude that rehabilitation planning may have beneficially accelerated the discharge of less ill day-patients, but that more resources are needed to prevent 'institutionalization' within the day-hospital.

Psychiatric morbidity in spouses of women admitted to a mother and baby unit

The spouses of 40 women admitted to a psychiatric Mother and Baby Unit were interviewed to detect psychiatric morbidity, and aspects of their social and marital functioning. This group was compared with 25 men whose wives had not shown obvious psychiatric disorder in the puerperium. Psychiatric morbidity, using DSM-III (American Psychiatric Association, 1980) criteria, was present in 42% of the index group, and 4% of the comparison group. The main diagnoses were major depressive episode and generalised anxiety disorder. This was associated with poorer marital and social function in the index group. Male psychopathology after delivery has been studied little but may be significant in the management of postpartum syndromes.

Long-stay patients in a psychiatric day hospital. A case note review

The case notes of all non-psychogeriatric patients attending the Psychiatric Day Hospital at the University Hospital of South Manchester during one week in October 1982 were reviewed. Clinical, demographic, social and occupational data were gathered for all patients, and their attendance at the day hospital monitored for the year following the census period. No significant differences between patients could be found on any of the factors that it was predicted would distinguish short from long-stay patients. The best predictor of length of day hospital attendance in the current admission was the total quantity of previous hospital treatment whether as an in-patient or a day-patient. It is concluded that in the day hospital studied all patients had similar characteristics, and the majority could be seen as 'new long-stay' patients. The implications of this finding are discussed.

Assessing the benefits of psychotherapy: the economic approach

Recent debate about the place of psychotherapy in the National Health Service, while emphasising the importance of economic evaluation, has concentrated almost exclusively on issues of clinical outcome. This paper argues that the debate has focussed on too narrow a definition of psychotherapy and too limited a view of the possible effects of psychotherapy, both good and bad. It reviews evidence concerning the demand and need for psychotherapy services in a number of clinical settings, and discusses the economic implications of the provision of such services. Economic studies of psychotherapy are reviewed and a conclusion drawn that it might be possible to justify the provision of psychotherapy services on economic grounds, but that considerably more research needs to be done in this area. The directions such future research might take are outlined.

Cardiac dysfunction during status epilepticus in the neonatal pig

Cardiovascular complications frequently occur during status epilepticus. To determine the changes in systemic and pulmonary arterial pressure, cardi output, and left ventricular contractility during seizures, 1-week-old pigs were intubated, paralyzed, mechanicall entilated, and catheterized with a Swan-Ganz catheter. Seizures were induced with intravenous bicuculline. Early changes consisted of significant systemic and pulmonary arterial hypertension. After 2 hours of seizures, the animals developed progressive systemic hypotension and decreased cardiac output. M-mode echocardiography disclosed a decrease in left ventricular contractility. Cardiac tissue frozen in situ showed a significant increase in lactate and reductions in glucose, triglyceride, and adenosine triphosphate levels. Prolonged seizures in the neonatal pig result in cardiac dysfunction, which may play a role in the development of epileptic brain damage.

Humour in group psychotherapy

The role of humour in group psychotherapy has received scant attention from both clinician and researcher. We have identified, and attempted to classify, several uses to which humour can be put in a group. We also point out the destructive potential of humour, and categorize its misapplications. We hope our scheme will serve as a framework within which systematic research can be conducted.