1
|
Casetta C, Santosh P, Bayley R, Bisson J, Byford S, Dixon C, Drake RJ, Elvins R, Emsley R, Fung N, Hayes D, Howes O, James A, James K, Jones R, Killaspy H, Lennox B, Marchant L, McGuire P, Oloyede E, Rogdaki M, Upthegrove R, Walters J, Egerton A, MacCabe JH. CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings. BMC Psychiatry 2024; 24:122. [PMID: 38355533 PMCID: PMC10865566 DOI: 10.1186/s12888-023-05397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU. METHODS AND DESIGN This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old). AIM AND OBJECTIVES The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks. DISCUSSION The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis. TRIAL REGISTRATION ISRCTN Number: 37176025, IRAS Number: 1004947. TRIAL STATUS In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.
Collapse
Affiliation(s)
- C Casetta
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - P Santosh
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Bayley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C Dixon
- Wonford House Hospital, Devon Partnership NHS Trust, Exeter, UK
| | - R J Drake
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - R Elvins
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - R Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - N Fung
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - D Hayes
- South London and Maudsley NHS Foundation Trust, London, UK
| | - O Howes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A James
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - K James
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - R Jones
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - H Killaspy
- Division of Psychiatry, University College London, London, UK
| | - B Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - L Marchant
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P McGuire
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - E Oloyede
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - M Rogdaki
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Womens and Childrens NHS Foundation Trust, Birmingham, UK
| | - J Walters
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - A Egerton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
2
|
Byford S, Madhok D, Baldan P, Amey G, Barber J, Harris R, Walker G. Introduction of the day case total laparoscopic hysterectomy (TLH) protocol. Aust N Z J Obstet Gynaecol 2022; 62:881-886. [PMID: 35906724 DOI: 10.1111/ajo.13598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traditionally total laparoscopic hysterectomy (TLH) patients are admitted for 1-2 days post-operatively. Day case TLH has been proven to be feasible and safe in other countries; however, this tertiary Queensland hospital is one of the first Australian institutions to introduce a day case TLH protocol. AIM To pilot the implementation of our day case TLH protocol assessing the feasibility, safety and patient satisfaction of same-day discharge. MATERIALS AND METHODS A retrospective audit of the implementation of our day case TLH protocol at a tertiary Queensland hospital was conducted. Primary outcome was length of post-operative hospital stay. Secondary outcomes included perioperative complications and post-operative re-presentation rates. Patient satisfaction was assessed through a patient questionnaire. RESULTS Seventy-seven patients were included in the study. There were 94.81% patients who went home on the same day. Their average length of post-operative hospital stay was 7.72 (SD ± 3.36) hours. Of the patients who did achieve same-day discharge, the average length of stay was 7.05 (SD ±1.46) hours. There were no significant differences in perioperative complications or re-presentation rates compared to previously published literature. Patients reported they were extremely satisfied with day case TLH. CONCLUSION The implementation of our day case TLH protocol is feasible, safe and well received by patients in our tertiary Australian hospital. These results can have multimodal effects in healthcare: decrease in hospital costs by reducing length of stay and overnight admissions, improved theatre efficiency and patient flow, while maintaining patient safety and satisfaction.
Collapse
Affiliation(s)
- Sally Byford
- Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Drishti Madhok
- Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Paula Baldan
- Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Guy Amey
- Anesthetics, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Barber
- Obstetrics and Gynaecology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Rhys Harris
- Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Graeme Walker
- Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| |
Collapse
|
3
|
Byford S, Janssens S, Cook R. Implementing the transvaginal ultrasound simulation training (TRUSST) programme for obstetric registrars. Adv Simul (Lond) 2021; 6:1. [PMID: 33436097 PMCID: PMC7805035 DOI: 10.1186/s41077-020-00152-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transvaginal ultrasound (TVUS) training opportunities are limited due to its intimate nature; however, TVUS is an important component of early pregnancy assessment. Simulation can bridge this learning gap. AIM To describe and measure the effect of a transvaginal ultrasound simulation programme for obstetric registrars. MATERIALS AND METHODS The transvaginal ultrasound simulation training (TRUSST) curriculum consisted of supported practice using virtual reality transvaginal simulators (ScanTrainer, Medaphor) and communication skills training to assist obstetric registrars in obtaining required competencies to accurately and holistically care for women with early pregnancy complications. Trainee experience of live transvaginal scanning was evaluated with a questionnaire. Programme evaluation was by pre-post self-reported confidence level and objective pre-post training assessment using Objective Structured Assessment of Ultrasound Skills (OSAUS) and modified Royal Australian and New Zealand College of Obstetrics and Gynaecology assessment scores. Quantitative data was compared using paired t tests. RESULTS Fifteen obstetric registrars completed the programme. Numbers of performed live transvaginal ultrasound by trainees were low. Participants reported an increase in confidence level in performing a TVUS following training: mean pre score 1.6/5, mean post score 3/5. Objective assessments improved significantly across both OSAUS and RANZCOG scores following training; mean improvement scores 7.6 points (95% CI 6.2-8.9, p < 0.05) and 32.5 (95% CI 26.4-38.6, p < 0.05) respectively. It was noted that scores for a systematic approach and documentation were most improved: 1.9 (95% CI 1.4-2.5, p < 0.05) and 2.1 (95% CI 1.5-2.7, p < 0.05) respectively. CONCLUSION The implementation of a simulation-based training curriculum resulted in improved confidence and ability in TVUS scanning, especially with regard to a systematic approach and documentation.
Collapse
Affiliation(s)
- Sally Byford
- Mater Health, Mater Hospital, Brisbane, Australia
| | | | - Rachel Cook
- Mater Health, Mater Hospital, Brisbane, Australia
| |
Collapse
|
4
|
Evans-Lacko S, Courtin E, Fiorillo A, Knapp M, Luciano M, Park AL, Brunn M, Byford S, Chevreul K, Forsman A, Gulacsi L, Haro J, Kennelly B, Knappe S, Lai T, Lasalvia A, Miret M, O'Sullivan C, Obradors-Tarragó C, Rüsch N, Sartorius N, Švab V, van Weeghel J, Van Audenhove C, Wahlbeck K, Zlati A, McDaid D, Thornicroft G. The state of the art in European research on reducing social exclusion and stigma related to mental health: A systematic mapping of the literature. Eur Psychiatry 2020; 29:381-9. [DOI: 10.1016/j.eurpsy.2014.02.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/16/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022] Open
Abstract
AbstractStigma and social exclusion related to mental health are of substantial public health importance for Europe. As part of ROAMER (ROAdmap for MEntal health Research in Europe), we used systematic mapping techniques to describe the current state of research on stigma and social exclusion across Europe. Findings demonstrate growing interest in this field between 2007 and 2012. Most studies were descriptive (60%), focused on adults of working age (60%) and were performed in Northwest Europe—primarily in the UK (32%), Finland (8%), Sweden (8%) and Germany (7%). In terms of mental health characteristics, the largest proportion of studies investigated general mental health (20%), common mental disorders (16%), schizophrenia (16%) or depression (14%). There is a paucity of research looking at mechanisms to reduce stigma and promote social inclusion, or at factors that might promote resilience or protect against stigma/social exclusion across the life course. Evidence is also limited in relation to evaluations of interventions. Increasing incentives for cross-country research collaborations, especially with new EU Member States and collaboration across European professional organizations and disciplines, could improve understanding of the range of underpinning social and cultural factors which promote inclusion or contribute toward lower levels of stigma, especially during times of hardship.
Collapse
|
5
|
Blackwood R, Wolstenholme A, Kimergård A, Fincham-Campbell S, Khadjesari Z, Coulton S, Byford S, Deluca P, Jennings S, Currell E, Dunne J, O'Toole J, Winnington J, Finch E, Drummond C. Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial. BMC Public Health 2020; 20:332. [PMID: 32171278 PMCID: PMC7071678 DOI: 10.1186/s12889-020-8437-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. METHODS One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. DISCUSSION AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. TRIAL REGISTRATION International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.
Collapse
Affiliation(s)
- R Blackwood
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - A Wolstenholme
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - A Kimergård
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Fincham-Campbell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Z Khadjesari
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Coulton
- University of Kent, Kent, Canterbury, UK
| | - S Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - P Deluca
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Jennings
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - E Currell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - J Dunne
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - J O'Toole
- NIHR Collaborations for Leadership in Applied Health Research and Care South London, London, UK
| | - J Winnington
- South London and the Maudsley NHS Foundation Trust, London, UK
| | - E Finch
- South London and the Maudsley NHS Foundation Trust, London, UK
| | - C Drummond
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
6
|
Trevillion K, Ryan EG, Pickles A, Heslin M, Byford S, Nath S, Bick D, Milgrom J, Mycroft R, Domoney J, Pariante C, Hunter MS, Howard LM. An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial. J Affect Disord 2020; 261:187-197. [PMID: 31634678 DOI: 10.1016/j.jad.2019.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/30/2019] [Accepted: 10/09/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Depression is a common antenatal mental disorder associated with significant maternal morbidity and adverse fetal outcomes. However, there is a lack of research on the effectiveness or cost-effectiveness of psychological interventions for antenatal depression. METHODS A parallel-group, exploratory randomised controlled trial across five hospitals. The trial compared Guided Self-Help, modified for pregnancy, plus usual care with usual care alone for pregnant women meeting DSM-IV criteria for mild-moderate depression. The trial objectives were to establish recruitment/follow-up rates, compliance and acceptability, and to provide preliminary evidence of intervention efficacy and cost-effectiveness. The primary outcome of depressive symptoms was assessed by blinded researchers using the Edinburgh Postnatal Depression Scale at 14-weeks post-randomisation. RESULTS 620 women were screened, 114 women were eligible and 53 (46.5%) were randomised. 26 women received Guided Self-Help - 18 (69%) attending ≥4 sessions - and 27 usual care; n = 3 women were lost to follow-up (follow-up rate for primary outcome 92%). Women receiving Guided Self-Help reported fewer depressive symptoms at follow-up than women receiving usual care (adjusted effect size -0.64 (95%CI: -1.30, 0.06) p = 0.07). There were no trial-related adverse events. The cost-effectiveness acceptability curve showed the probability of Guided Self-Help being cost-effective compared with usual care ranged from 10 to 50% with a willingness-to-pay range from £0 to £50,000. CONCLUSIONS AND LIMITATIONS Despite intense efforts we did not meet our anticipated recruitment target. However, high levels of acceptability, a lack of adverse events and a trend towards improvements in symptoms of depression post-treatment indicates this intervention is suitable for talking therapy services.
Collapse
Affiliation(s)
- K Trevillion
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom.
| | - E G Ryan
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - A Pickles
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - M Heslin
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - S Nath
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - D Bick
- Departmentof Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom
| | - J Milgrom
- University of Melbourne and Parent-Infant Research Institute, Melbourne, Australia
| | - R Mycroft
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - J Domoney
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - C Pariante
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - M S Hunter
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| | - L M Howard
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, United Kingdom
| |
Collapse
|
7
|
Titheradge D, Hayes R, Longdon B, Allen K, Price A, Hansford L, Nye E, Ukoumunne O, Byford S, Norwich B, Fletcher M, Logan S, Ford T. Psychological distress among primary school teachers: a comparison with clinical and population samples. Public Health 2019; 166:53-56. [DOI: 10.1016/j.puhe.2018.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/31/2018] [Accepted: 09/25/2018] [Indexed: 11/26/2022]
|
8
|
Nair A, Turner C, Heyman I, Mataix-Cols D, Lovell K, Krebs G, Lang K, Byford S, O’Kearney R. Moderators and predictors of outcomes in telephone delivered compared to face-to-face cognitive behaviour therapy for paediatric obsessive–compulsive disorder: preliminary evidence from a non-inferiority RCT. Cogn Behav Ther 2018; 48:353-368. [DOI: 10.1080/16506073.2018.1513555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- A. Nair
- Research School of Psychology, Australian National University, Canberra, Australia
| | - C. Turner
- School of Psychology, Australian Catholic University, Brisbane, Australia
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - I. Heyman
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - D. Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - K. Lovell
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - G. Krebs
- Kings College London, Institute of Psychiatry, London, United Kingdom
| | - K. Lang
- Kings College London, Institute of Psychiatry, London, United Kingdom
| | - S. Byford
- Kings College London, Institute of Psychiatry, London, United Kingdom
| | - R. O’Kearney
- Research School of Psychology, Australian National University, Canberra, Australia
| |
Collapse
|
9
|
Metrebian N, Weaver T, Pilling S, Hellier J, Byford S, Shearer J, Mitcheson L, Astbury M, Bijral P, Bogdan N, Bowden-Jones O, Day E, Dunn J, Finch E, Forshall S, Glasper A, Morse G, Akhtar S, Bajaria J, Bennett C, Bishop E, Charles V, Davey C, Desai R, Goodfellow C, Haque F, Little N, McKechnie H, Morris J, Mosler F, Mutz J, Pauli R, Poovendran D, Slater E, Strang J. Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management. Contemp Clin Trials 2018; 71:124-132. [PMID: 29908336 DOI: 10.1016/j.cct.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 10/14/2022]
Abstract
There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice. Trial registration ISRCTN 01591254.
Collapse
Affiliation(s)
- N Metrebian
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK.
| | - T Weaver
- Imperial College London, London, UK; Middlesex University, London, UK
| | - S Pilling
- University College London, London, UK
| | - J Hellier
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - S Byford
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - J Shearer
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - L Mitcheson
- South London and Maudsley NHS Foundation Trust, London, UK
| | - M Astbury
- Dudley & Walsall Mental Health Partnership Trust, Dudley, UK
| | - P Bijral
- Change, Grow, Live Charity, Management Offices, London, UK
| | - N Bogdan
- South Essex Partnership NHS Foundation Trust, Essex, UK
| | - O Bowden-Jones
- Central and North West London NHS Foundation Trust, London, UK
| | - E Day
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK; Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - J Dunn
- Camden & Islington NHS Foundation Trust, London, UK
| | - E Finch
- South London and Maudsley NHS Foundation Trust, London, UK
| | - S Forshall
- Avon & Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - A Glasper
- Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - G Morse
- Turning Point Charity, London, UK
| | - S Akhtar
- Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - J Bajaria
- South Essex Partnership NHS Foundation Trust, Essex, UK
| | - C Bennett
- Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - E Bishop
- University College London, London, UK
| | - V Charles
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - C Davey
- Avon & Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - R Desai
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | | | - F Haque
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - N Little
- University College London, London, UK
| | | | - J Morris
- Avon & Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
| | - F Mosler
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - J Mutz
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - R Pauli
- Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | | | - E Slater
- South Essex Partnership NHS Foundation Trust, Essex, UK
| | - J Strang
- King's College London, National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
10
|
Kalinowski L, Byford S, Perry-Keene J. Primary retroperitoneal mucinous cystadenoma with borderline malignancy. Pathology 2016. [DOI: 10.1016/j.pathol.2015.12.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. O-90 Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: Clinical outcomes and implementation. BMJ Support Palliat Care 2015. [DOI: 10.1136/bmjspcare-2015-000978.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
12
|
Lynch TR, Whalley B, Hempel RJ, Byford S, Clarke P, Clarke S, Kingdon D, O'Mahen H, Russell IT, Shearer J, Stanton M, Swales M, Watkins A, Remington B. Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomised trial. BMJ Open 2015; 5:e008857. [PMID: 26187121 PMCID: PMC4513446 DOI: 10.1136/bmjopen-2015-008857] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/30/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Only 30-40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression. METHODS AND ANALYSIS REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective. ETHICS AND DISSEMINATION The National Research Ethics Service (NRES) Committee South Central - Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146. TRIAL REGISTRATION NUMBER ISRCTN85784627.
Collapse
Affiliation(s)
- T R Lynch
- Department of Psychology, University of Southampton, Southampton, UK
| | - B Whalley
- Department of Psychology, University of Plymouth, Plymouth, UK
| | - R J Hempel
- Department of Psychology, University of Southampton, Southampton, UK
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P Clarke
- Institute for Social and Economic Research, University of Essex, Colchester, UK
| | - S Clarke
- University Department of Mental Health, Bournemouth University and Intensive Psychological Therapies Service, Dorset Health Care University NHS Foundation Trust, Poole, UK
| | - D Kingdon
- Department of Medicine, University of Southampton, Southampton, UK
| | - H O'Mahen
- Mood Disorders Centre, University of Exeter, Exeter, UK
| | - I T Russell
- College of Medicine, Swansea University, Swansea, UK
| | - J Shearer
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - M Stanton
- Psychology Services, Southern Health NHS Foundation Trust, Winchester, UK
| | - M Swales
- School of Psychology, Bangor University, Bangor, UK
| | - A Watkins
- College of Medicine, Swansea University, Swansea, UK
| | - B Remington
- Department of Psychology, University of Southampton, Southampton, UK
| |
Collapse
|
13
|
Slade M, Byford S, Barrett B, Lloyd-Evans B, Gilburt H, Osborn DPJ, Skinner R, Leese M, Thornicroft G, Johnson S. Alternatives to standard acute in-patient care in England: short-term clinical outcomes and cost-effectiveness. Br J Psychiatry 2014; 53:s14-9. [PMID: 20679274 DOI: 10.1192/bjp.bp.110.081059] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched. AIMS To explore short-term outcomes and costs of admission to alternative and standard services. METHOD Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services. RESULTS All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12-2.86), TAG (difference 1.40, 95% CI 0.39-2.51) and GAF functioning (difference 4.15, 95% CI 1.08-7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK pound3832 v. pound9850). Standard services cost an additional pound2939 per unit HoNOS improvement. CONCLUSIONS The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.
Collapse
Affiliation(s)
- M Slade
- Health Service and Population Research Department, Box PO29, Institute of Psychiatry, King's College London, De Crespigny Park, Denmark Hill, London SE5 8AF, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Howard L, Flach C, Leese M, Byford S, Killaspy H, Cole L, Lawlor C, Betts J, Sharac J, Cutting P, McNicholas S, Johnson S. Effectiveness and cost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilot patient-preference randomised controlled trial. Br J Psychiatry 2014; 53:s32-40. [PMID: 20679277 DOI: 10.1192/bjp.bp.110.081083] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards. AIMS To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP-RCT) design (ISRCTN20804014). METHOD We used a PP-RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission. RESULTS Forty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (randomised or preference arms), but women who obtained their preferred intervention were more satisfied with treatment. CONCLUSIONS Although the sample sizes were too small to allow definite conclusions, the results suggest that when services are able to provide interventions preferred by patients, those patients are more likely to be satisfied with treatment. This pilot study provides some evidence that women's crisis houses are as effective as traditional psychiatric wards, and may be more cost-effective.
Collapse
Affiliation(s)
- L Howard
- Health Service and Population Research Department, Institute of Psychiatry, Box PO29, De Crespigny Park, London SE5 8AF, UK.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Byford S, Weaver E, Anstey C. Has the incidence of hypoxic ischaemic encephalopathy in Queensland been reduced with improved education in fetal surveillance monitoring? Aust N Z J Obstet Gynaecol 2014; 54:348-53. [PMID: 24597944 DOI: 10.1111/ajo.12200] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 02/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypoxic ischaemic encephalopathy (HIE) is secondary to intrapartum asphyxia and the fifth largest cause of death of children under five. Incorrect use and interpretation of intrapartum cardiotocographs has been identified as a contributing factor to the development of HIE. Therefore, RANZCOG introduced the Fetal Surveillance Education Program (FSEP) to improve education and practice of intrapartum care. AIM To investigate the incidence of HIE throughout Queensland between 2003 and 2011 during the introduction and implementation of RANZCOG FSEP. METHODS The incidence of HIE admissions at each hospital in Queensland (2003-2011) was collated from Queensland Health Statistics Centre. RANZCOG FSEP provided data regarding course attendees throughout Queensland (2006-2011). Hospitals were grouped into four regions. Statistical analysis was conducted using Stata(TM) (version 12.0) - data appeared to follow a damped harmonic model. RESULTS The posteducation (2006-2011) HIE rate was significantly lower (P = 0.02) than the pre-education (2003-2005) rate. The final model predicted a stabilisation of HIE occurrence rate at approximately 160 events/100,000 live births by 2012. This rate was stable if the level of education was maintained but rose back to the initial rate of 250 events/100,000 live births if the education participation was discontinued. CONCLUSIONS This study identified a significant reduction in the incidence of HIE--a potentially life-threatening newborn condition--between 2003 and 2011, during and following FSEP implementation. Notwithstanding the inevitable limitations of state-based data collection, these results are encouraging. For such improvements to be sustained, education must reach all staff engaged in intrapartum care and be regularly repeated.
Collapse
Affiliation(s)
- Sally Byford
- Department of Obstetrics & Gynaecology, Nambour General Hospital, Nambour, Queensland, Australia
| | | | | |
Collapse
|
16
|
Crawford MJ, Killaspy H, Barnes TR, Barrett B, Byford S, Clayton K, Dinsmore J, Floyd S, Hoadley A, Johnson T, Kalaitzaki E, King M, Leurent B, Maratos A, O'Neill FA, Osborn D, Patterson S, Soteriou T, Tyrer P, Waller D. Group art therapy as an adjunctive treatment for people with schizophrenia: a randomised controlled trial (MATISSE). Health Technol Assess 2012; 16:iii-iv, 1-76. [PMID: 22364962 DOI: 10.3310/hta16080] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To examine the clinical effectiveness and cost-effectiveness of referral to group art therapy plus standard care, compared with referral to an activity group plus standard care and standard care alone, among people with schizophrenia. DESIGN A three-arm, parallel group, single-blind, pragmatic, randomised controlled trial. Participants were randomised via an independent and remote telephone randomisation service using permuted blocks, stratified by study centre. SETTING Study participants were recruited from secondary care mental health and social services in four UK centres. PARTICIPANTS Potential participants were aged 18 years or over, had a clinical diagnosis of schizophrenia, confirmed by an examination of case notes, and provided written informed consent. We excluded those who were unable to speak sufficient English to complete the baseline assessment, those with severe cognitive impairment and those already receiving arts therapy. INTERVENTIONS Group art therapy was delivered by registered art therapists according to nationally agreed standards. Groups had up to eight members, lasted for 90 minutes and ran for 12 months. Members were given access to a range of art materials and encouraged to use these to express themselves freely. Activity groups were designed to control for the non-specific effects of group art therapy. Group facilitators offered various activities and encouraged participants to collectively select those they wanted to pursue. Standard care involved follow-up from secondary care mental health services and the option of referral to other services, except arts therapies, as required. MAIN OUTCOME MEASURES Our co-primary outcomes were global functioning (measured using the Global Assessment of Functioning Scale - GAF) and mental health symptoms (measured using the Positive and Negative Syndrome Scale - PANSS) at 24 months. The main secondary outcomes were level of group attendance, social functioning, well-being, health-related quality of life, service utilisation and other costs measured 12 and 24 months after randomisation. RESULTS Four hundred and seventeen people were recruited, of whom 355 (85%) were followed up at 2 years. Eighty-six (61%) of those randomised to art therapy and 73 (52%) of those randomised to activity groups attended at least one group. No differences in primary outcomes were found between the three study arms. The adjusted mean difference between art therapy and standard care at 24 months was -0.9 [95% confidence interval (CI) -3.8 to 2.1] on the GAF Scale and 0.7 (95% CI -3.1 to 4.6) on the PANSS Scale. Differences in secondary outcomes were not found, except that those referred to an activity group had fewer positive symptoms of schizophrenia at 24 months than those randomised to art therapy. Secondary analysis indicated that attendance at art therapy groups was not associated with improvements in global functioning or mental health. Although the total cost of the art therapy group was lower than the cost of the two comparison groups, referral to group art therapy did not appear to provide a cost-effective use of resources. CONCLUSIONS Referring people with established schizophrenia to group art therapy as delivered in this randomised trial does not appear to improve global functioning or mental health of patients or provide a more cost-effective use of resources than standard care alone. TRIAL REGISTRATION Current Controlled Trials ISRCTN 46150447. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 8. See the HTA programme website for further project information.
Collapse
Affiliation(s)
- M J Crawford
- Centre for Mental Health, Imperial College London, London, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Howard L, Flach C, Leese M, Byford S, Killaspy H, Johnson S. Effectiveness and cost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilot patient-preference randomised controlled trial. Psychiat Prax 2011. [DOI: 10.1055/s-0031-1277763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
18
|
Green JM, Wood AJ, Kerfoot MJ, Trainor G, Roberts C, Rothwell J, Woodham A, Ayodeji E, Barrett B, Byford S, Harrington R. Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation. BMJ 2011; 342:d682. [PMID: 21459975 PMCID: PMC3069684 DOI: 10.1136/bmj.d682] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people. DESIGN Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress. PARTICIPANTS Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care. Setting Eight child and adolescent mental health services in the northwest UK. INTERVENTIONS Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres. MAIN OUTCOME MEASURES Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded. RESULTS 183 adolescents were allocated to each arm (total n = 366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P = 0.95) at 6 months and 0.88 (0.59 to 1.33, P = 0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to 1.20, P = 0.29) at 6 months and 0.94 (0.63 to 1.40, P = 0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21,781) than for routine care (£15,372) but the difference was not significant (95% CI -1416 to 10782, P = 0.132). CONCLUSIONS The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations. Trial registration ISRCTN 20496110.
Collapse
Affiliation(s)
- J M Green
- Psychiatry Research Group, University of Manchester, Manchester M13 9PL, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Gowers SG, Clark AF, Roberts C, Byford S, Barrett B, Griffiths A, Edwards V, Bryan C, Smethurst N, Rowlands L, Roots P. A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess 2010; 14:1-98. [PMID: 20334748 DOI: 10.3310/hta14150] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To evaluate the clinical effectiveness and cost-effectiveness of inpatient compared with outpatient treatment and general (routine) treatment in Child and Adolescent Mental Health Services (CAMHS) against specialist treatment for young people with anorexia nervosa. In addition, to determine young people's and their carers' satisfaction with these treatments. DESIGN A population-based, pragmatic randomised controlled trial (RCT) was carried out on young people age 12 to 18 presenting to community CAMHS with anorexia nervosa. SETTING Thirty-five English CAMHS in the north-west of England co-ordinated through specialist centres in Manchester and Liverpool. PARTICIPANTS Two hundred and fifteen young people (199 female) were identified, of whom 167 (mean age 14 years 11 months) were randomised and 48 were followed up as a preference group. INTERVENTIONS Randomised patients were allocated to either inpatient treatment in one of four units with considerable experience in the treatment of anorexia nervosa, a specialist outpatient programme delivered in one of two centres, or treatment as usual in general community CAMHS. The outpatient programmes spanned 6 months of treatment. The length of inpatient treatment was determined on a case-by-case basis on clinical need with outpatient follow-up to a minimum of 6 months. MAIN OUTCOME MEASURES Follow-up assessments were carried out at 1, 2 and 5 years. The primary outcome measure was the Morgan-Russell Average Outcome Scale (MRAOS) and associated categorical outcomes. Secondary outcome measures included physical measures of weight, height, body mass index (BMI) and % weight for height. Research ratings included the Health of the National Outcome Scale for Children and Adolescents (HoNOSCA). Self report measures comprised the user version of HoNOSCA (HoNOSCA-SR), the Eating Disorder Inventory 2 (EDI-2), the Family Assessment Device (FAD) and the recent Mood and Feelings Questionnaire (MFQ). Information on resource use was collected in interview at 1, 2 and 5 years using the Child and Adolescent Service Use Schedule (CA-SUS). Satisfaction was measured quantitatively using a questionnaire designed for the study and qualitative (free) responses on it. The questionnaire data were supplemented by qualitative analysis of user and carer focus groups. RESULTS Of the 167 patients randomised, 65% adhered to the allocated treatment. Adherence was lower for inpatient treatment (49%) than for general CAMHS (71%) or specialist outpatient treatment (77%) (p = 0.013). Every subject was traced at both 1 and 2 years, with the main outcome measure completed (through contact with the subject, family members or clinicians), by 94% at 1 year, 93% at 2 years, but only 47% at 5 years. A validated outcome category was assigned for 98% at 1 year, 96% at 2 years and 60% at 5 years. There was significant improvement in all groups at each time point, with the number achieving a good outcome being 19% at 1 year, 33% at 2 years and 64% (of those followed up) at 5 years. Analysis demonstrated no difference in treatment effectiveness of randomisation to inpatient compared with outpatient treatment, or, specialist over generalist treatment at any time point, when baseline characteristics were taken into account. Generalist CAMHS treatment was slightly more expensive over the first 2 years of the study, largely because greater numbers were subsequently admitted to hospital after the initial treatment phase. The specialist outpatient programme was the dominant treatment in terms of incremental cost-effectiveness. Specialist treatments had a higher probability of being more cost-effective than generalist treatments and outpatient treatment had a higher probability of being more cost-effective than inpatient care. Parental satisfaction with treatment was generally good, though better with specialist than generalist treatment. Young people's satisfaction was much more mixed, but again better with specialist treatment, including inpatient care. CONCLUSION Poor adherence to randomisation (despite initial consent to it), limits the assessment of the treatment effect of inpatient care. However, this study provides little support for lengthy inpatient psychiatric treatment on clinical or health economic grounds. These findings are broadly consistent with existing guidelines on the treatment of anorexia nervosa, which suggest that outpatient treatments should be offered to the majority, with inpatient treatment offered in rare cases, though our findings lend little support to a stepped-care approach in which inpatient care is offered to outpatient non-responders. Outpatient care, supported by brief (medical) inpatient management for correction of acute complications may be a preferable approach. The health economic analysis and user views both support NICE guidelines, which suggest that anorexia nervosa should be managed in specialist services that have experience and expertise in its management. Comprehensive general CAMHS might, however, be well placed to manage milder cases. Further research should focus on the specific components of outpatient psychological therapies. Although family-based treatments are well established, trials have not established their effectiveness compared with good-quality individual psychological therapies and the combination of individual and family approaches is untested. Further research is needed to establish which patients (if any) might respond to inpatient psychiatric treatment when unresponsive to outpatient care, the positive and negative components of it and the optimum length of stay. TRIAL REGISTRATION NRR number (National Research Register) N0484056615; Current Controlled Trials ISRCTN39345394.
Collapse
|
20
|
Goodyer IM, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, Breen S, Ford C, Barrett B, Leech A, Rothwell J, White L, Harrington R. A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial. Health Technol Assess 2008; 12:iii-iv, ix-60. [PMID: 18462573 DOI: 10.3310/hta12140] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes. DESIGN A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation. SETTING Six English CAMHS participated in the study. PARTICIPANTS A total of 208 patients aged between 11 and 17 years were recruited and randomised. INTERVENTIONS All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT. MAIN OUTCOME MEASURES The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS). RESULTS Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13). CONCLUSIONS For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.
Collapse
Affiliation(s)
- I M Goodyer
- Developmental Psychiatry Section, Department of Psychiatry, University of Cambridge, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Byford S, Barrett B, Roberts C, Wilkinson P, Dubicka B, Kelvin RG, White L, Ford C, Breen S, Goodyer I. Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive behavioural therapy in adolescents with major depression. Br J Psychiatry 2007; 191:521-7. [PMID: 18055956 DOI: 10.1192/bjp.bp.107.038984] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Major depression is an important and costly problem among adolescents, yet evidence to support the provision of cost-effective treatments is lacking. AIMS To assess the short-term cost-effectiveness of combined selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural therapy (CBT) together with clinical care compared with SSRIs and clinical care alone in adolescents with major depression. METHOD Pragmatic randomised controlled trial in the UK. Outcomes and costs were assessed at baseline, 12 and 28 weeks. RESULTS The trial comprised 208 adolescents, aged 11-17 years, with major or probable major depression who had not responded to a brief initial psychosocial intervention. There were no significant differences in outcome between the groups with and without CBT. Costs were higher in the group with CBT, although not significantly so (P=0.057). Cost-effectiveness analysis and exploration of the associated uncertainty suggest there is less than a 30% probability that CBT plus SSRIs is more cost-effective than SSRIs alone. CONCLUSIONS A combination of CBT plus SSRIs is not more cost-effective in the short-term than SSRIs alone for treating adolescents with major depression in receipt of routine specialist clinical care.
Collapse
Affiliation(s)
- S Byford
- King's College London, Centre for the Economics of Mental Health, Box P024, Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Fiander M, Burns T, Ukoumunne OC, Fahy T, Creed F, Tyrer P, Byford S. Do care patterns change over time in a newly established mental health service? A report from the UK700 trial. Eur Psychiatry 2006; 21:300-6. [PMID: 16824736 DOI: 10.1016/j.eurpsy.2005.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Accepted: 09/13/2005] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Data on the process of mental health care is scant. Most studies focus on services at their inception when activity may be atypical and then usually present data only mean values for the reported variables over the whole study period. We aimed to test whether care delivery changes over time, and to describe any changes at the individual patient and team levels. METHODS Process data on 272 patients in three new intensive case management (ICM) teams were collected over 2 years. Interventions were prospectively recorded using clinician-derived categories. Changes over time are described at both patient and team level. RESULTS The number of contacts and the proportion of face-to-face activity were remarkably constant after the first month at the patient level. The proportion of 'psychiatric' interventions (main focus on medication or a specific 'mental health' intervention performed) increased greatly after the first 6 months. The care activity received by individual patients varied considerably. Overall, teams varied significantly in the extent to which their activity rates were sustained over time. CONCLUSIONS New ICM teams deliver highly individualised care with more marked differences in treatment patterns between patients in the same team than mean differences between teams. The early 'engagement' period is marked by a greater focus on social care. There is evidence of differences in sustainability of the services by site.
Collapse
Affiliation(s)
- M Fiander
- Department of Mental Health, St. George's Hospital Medical School, London, UK
| | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
OBJECTIVE To examine the relationship between clinical, demographic and socio-economic characteristics and the long-term costs of a cohort of neurotic patients. METHOD Analysis of the costs of a cohort of 210 people entered in the Nottingham study of neurotic disorders, a randomized controlled evaluation of five treatments for neurotic disorders. Service use data were collected at 5 and 12 years after study entry. Multiple regression analyses were conducted. RESULTS The total cost per patient over the 12-year follow-up period was calculated to be $11,940 (SD $15,520) ( pound7450, SD pound9690). Higher costs were significantly associated with the presence of general neurotic syndrome, an initial diagnosis of dysthymia and a recurrent episode of illness. CONCLUSION The total costs of care for a range of neurotic disorders are broadly comparable with other estimates of costs reported in the literature for similar populations. Those responsible for higher costs in the longer-term have comorbid anxiety, depressive and personality disorders.
Collapse
Affiliation(s)
- G Knerer
- Department of Mental Health Sciences, Royal Free and University College School of Medicine, London, UK.
| | | | | | | | | |
Collapse
|
24
|
Byford S, Knapp M, Greenshields J, Ukoumunne OC, Jones V, Thompson S, Tyrer P, Schmidt U, Davidson K. Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach. Psychol Med 2003; 33:977-986. [PMID: 12946082 DOI: 10.1017/s0033291703008183] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death. METHOD Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves. RESULTS Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive. CONCLUSION Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.
Collapse
Affiliation(s)
- S Byford
- Department of Psychological Medicine, Imperial College, King's College and Maudsley Hospitals, Center for the Economics of Mental Health, Institute of Psychiatry, London
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Tyrer P, Thompson S, Schmidt U, Jones V, Knapp M, Davidson K, Catalan J, Airlie J, Baxter S, Byford S, Byrne G, Cameron S, Caplan R, Cooper S, Ferguson B, Freeman C, Frost S, Godley J, Greenshields J, Henderson J, Holden N, Keech P, Kim L, Logan K, Manley C, MacLeod A, Murphy R, Patience L, Ramsay L, De Munroz S, Scott J, Seivewright H, Sivakumar K, Tata P, Thornton S, Ukoumunne OC, Wessely S. Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychol Med 2003; 33:969-976. [PMID: 12946081 DOI: 10.1017/s0033291703008171] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm. METHOD Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months. RESULTS Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20). CONCLUSION Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.
Collapse
Affiliation(s)
- P Tyrer
- Department of Psychological Medicine, Imperial College, King's College and Maudsley Hospitals, Center for the Economics of Mental Health, Institute of Psychiatry, London
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Laugharne R, Byford S, Barber JA, Burns T, Walsh E, Marshall S, Tyrer P. The effect of alcohol consumption on cost of care in severe psychotic illness: a report from the UK700 study. Acta Psychiatr Scand 2002; 106:241-6. [PMID: 12197864 DOI: 10.1034/j.1600-0447.2002.02311.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Alcohol misuse in psychotic patients is common and leads to poor treatment outcome. This study examines the relationship between alcohol consumption and cost of care in patients with a severe psychotic illness. METHOD Patient care was evaluated over 2 years for 708 patients. Patient reported alcohol consumption was evaluated at initial interview. The outcome measure was cost of care over 2 years. RESULTS There was no difference in mean cost of care between non-drinkers, moderate and heavy drinkers. Increased alcohol consumption (measured as a continuous variable, adjusted for baseline characteristics) was associated with lower cost of care. CONCLUSION Heavier alcohol consumers did not incur more treatment costs and may, indeed, cost less than other patients. This may reflect higher levels of drinking being associated with better overall functioning, poorer engagement with services or exclusion from services.
Collapse
Affiliation(s)
- R Laugharne
- Department of General Psychiatry, St George's Hospital Medical School, London, UK.
| | | | | | | | | | | | | |
Collapse
|
27
|
Byford S, Barber JA, Fiander M, Marshall S, Green J. Factors that influence the cost of caring for patients with severe psychotic illness: report from the UK 700 trial. Br J Psychiatry 2001; 178:441-7. [PMID: 11331560 DOI: 10.1192/bjp.178.5.441] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many factors influence the type and quantity of services received by patients and, thus, the total cost of care. Knowledge of these factors can aid budgetary and service-planning decisions. AIMS To investigate factors that influence the cost of caring for patients with severe psychotic illness. METHOD Univariate and multivariate analyses were used to examine associations between baseline characteristics and subsequent 2-year total direct costs in 667 patients from the UK 700 case management trial. RESULTS Significantly more money was spent on younger patients, those with longer duration of illness, those who had spent less time living independently and those who had spent longer in hospital for psychiatric reasons. CONCLUSIONS Total costs of caring for patients with severe psychotic illness appear to be influenced to a large extent by age, duration of illness and past levels of dependence on statutory services. The strength of these relationships is greater than the impact of illness severity.
Collapse
Affiliation(s)
- S Byford
- Centre for the Economics of Mental Health, Institute of Psychiatry, London, UK.
| | | | | | | | | |
Collapse
|
28
|
King M, Sibbald B, Ward E, Bower P, Lloyd M, Gabbay M, Byford S. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technol Assess 2001; 4:1-83. [PMID: 11086269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner (GP) care compared with two types of brief psychological therapy (non-directive counselling and cognitive-behaviour therapy) in the management of depression as well as mixed anxiety and depression in the primary care setting. DESIGN The design was principally a pragmatic randomised controlled trial, but was accompanied by two additional allocation methods allowing patient preference: the option of a specific choice of treatment (preference allocation) and the option to be randomised between the psychological therapies only. Of the 464 patients allocated to the three treatments, 197 were randomised between the three treatments, 137 chose a specific treatment, and 130 were randomised between the psychological therapies only. The patients underwent follow-up assessments at 4 and 12 months. SETTING The study was conducted in 24 general practices in Greater Manchester and London. SUBJECTS A total of 464 eligible patients, aged 18 years and over, were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms. INTERVENTIONS The interventions consisted of brief psychological therapy (12 sessions maximum) or usual GP care. Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling. Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies. Usual GP care included discussions with patients and the prescription of medication, but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months. Most therapy sessions took place on a weekly basis in the general practices. By the 12-month follow-up, GP care in some cases did include referral to mental healthcare specialists. MAIN OUTCOME MEASURES The clinical outcomes included depressive symptoms, general psychiatric symptoms, social function and patient satisfaction. The economic outcomes included direct and indirect costs and quality of life. Assessments were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post. RESULTS At 4 months, both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care. Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4-5 points lower than the mean score of patients in the usual GP care group, a difference that was also clinically significant. These differences did not generalize to other measures of outcome. There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients randomised to a psychological therapy by either randomised allocation method. At 12 months, the patients in all three groups had improved to the same extent. The lack of a significant difference between the treatment groups at this point resulted from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups. At 4 months, patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group. However, by 12 months, patients who had received non-directive counselling were more satisfied than those in either of the other two groups. There were few differences in the baseline characteristics of patients who were randomised or expressed a treatment preference, and no differences in outcome between these patients. Similar outcomes were found for patients who chose either psychological therapy. Again, there were no significant differences between the two groups at 4 or 12 months. Patients who chose counselling were more satisfied with treatment than those who chose c
Collapse
Affiliation(s)
- M King
- Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School of University College London, UK
| | | | | | | | | | | | | |
Collapse
|
29
|
Hassiotis A, Ukoumunne OC, Byford S, Tyrer P, Harvey K, Piachaud J, Gilvarry K, Fraser J. Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial. Br J Psychiatry 2001; 178:166-71. [PMID: 11157431 DOI: 10.1192/bjp.178.2.166] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little research has been carried out on the benefits of intensive case management (ICM) for people with borderline IQ and severe mental illness. AIMS To compare outcome and costs of care of patients with severe psychotic illness with borderline IQ to patients of normal IQ and to assess whether ICM is more beneficial for the former than for the latter. METHOD The study utilises data from the UK700 multi-centre randomised controlled trial of case management. The main outcome measure was the number of days spent in hospital for psychiatric reasons. Secondary outcomes were costs of care and clinical outcome. RESULTS ICM was significantly more beneficial for borderline-IQ patients than those of normal IQ in terms of reductions in days spent in hospital, hospital admissions, total costs and needs and increased satisfaction. CONCLUSIONS ICM appears to be a cost-effective strategy for a subgroup of patients with severe psychosis with cognitive deficits.
Collapse
Affiliation(s)
- A Hassiotis
- Department of Psychiatry and Behavioural Sciences, RF & UCMS, Wolfson Building, 48 Riding House Street, London W1N AA, UK.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M, Gabbay M. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness. BMJ 2000; 321:1389-92. [PMID: 11099285 PMCID: PMC27543 DOI: 10.1136/bmj.321.7273.1389] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients. DESIGN Prospective, controlled trial with randomised and patient preference allocation arms. SETTING General practices in London and greater Manchester. PARTICIPANTS 464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion. INTERVENTIONS Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists. MAIN OUTCOME MEASURES Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production. RESULTS 197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis. CONCLUSIONS Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12 months.
Collapse
Affiliation(s)
- P Bower
- National Primary Care Research and Development Centre (NPCRDC), University of Manchester, UK
| | | | | | | | | | | | | |
Collapse
|
31
|
Burns T, Fiander M, Kent A, Ukoumunne OC, Byford S, Fahy T, Kumar KR. Effects of case-load size on the process of care of patients with severe psychotic illness. Report from the UK700 trial. Br J Psychiatry 2000; 177:427-33. [PMID: 11059996 DOI: 10.1017/s0007125000227359] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care. AIMS To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly. METHOD Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared. RESULTS Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes. CONCLUSIONS The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.
Collapse
Affiliation(s)
- T Burns
- Department of General Psychiatry, St George's Hospital Medical School, London, UK
| | | | | | | | | | | | | |
Collapse
|
32
|
Harrington R, Peters S, Green J, Byford S, Woods J, McGowan R. Randomised comparison of the effectiveness and costs of community and hospital based mental health services for children with behavioural disorders. BMJ 2000; 321:1047-50. [PMID: 11053174 PMCID: PMC27511 DOI: 10.1136/bmj.321.7268.1047] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that a community based intervention by secondary child and adolescent mental health services would be significantly more effective and less costly than a hospital based intervention. DESIGN Open study with two randomised parallel groups. SETTING Two health districts in the north of England. PARTICIPANTS Parents of 3 to 10 year old children with behavioural disorder who had been referred to child and adolescent mental health services. INTERVENTION Parental education groups. MAIN OUTCOME MEASURES Parents' and teachers' reports of the child's behaviour, parental depression, parental criticism of the child, impact of the child's behaviour on the family. RESULTS 141 subjects were randomised to community (n=72) or hospital (n=69) treatment. Primary outcome data were obtained on 115 (82%) cases a year later. Intention to treat analyses showed no significant differences between the community and hospital based groups on any of the outcome measures, or on costs. Parental depression was common and predicted the child's outcome. CONCLUSIONS Location of child mental health services may be less important than the range of services that they provide, which should include effective treatment for parents' mental health problems.
Collapse
Affiliation(s)
- R Harrington
- Department of Child and Adolescent Psychiatry, University of Manchester, Manchester M27 4HA, UK.
| | | | | | | | | | | |
Collapse
|
33
|
Hassiotis A, Ukoumunne O, Byford S, Tyrer P, Harvey K, Piachaud J, Gilvarry C. FC10.01 Outcome of Patients with Severe Mental Illness and Borderline Intellectual Functioning. Eur Psychiatry 2000. [DOI: 10.1016/s0924-9338(00)94273-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
34
|
Affiliation(s)
- S Byford
- Centre for Health Economics, University of York, York YO10 5DD
| | | | | |
Collapse
|
35
|
Affiliation(s)
- S Palmer
- Centre for Health Economics, University of York, York YO1 5DD
| | | | | |
Collapse
|
36
|
Byford S, Harrington R, Torgerson D, Kerfoot M, Dyer E, Harrington V, Woodham A, Gill J, McNiven F. Cost-effectiveness analysis of a home-based social work intervention for children and adolescents who have deliberately poisoned themselves. Results of a randomised controlled trial. Br J Psychiatry 1999; 174:56-62. [PMID: 10211152 DOI: 10.1192/bjp.174.1.56] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little evidence exists regarding the effectiveness or cost-effectiveness of alternative treatment services in the field of child and adolescent psychiatry. AIMS To assess the cost-effectiveness of a home-based social work intervention for young people who have deliberately poisoned themselves. METHOD Children aged < or = 16 years, referred to child mental health teams with a diagnosis of deliberate self-poisoning were randomly allocated to either routine care (n = 77) or routine care plus the social work intervention (n = 85). Clinical and resource-use data were assessed over six months from the date of trial entry. RESULTS No significant differences were found between the two groups in terms of the main outcome measures or costs. In a sub-group of children without major depression, suicidal ideation was significantly lower in the intervention group at the six-month follow-up (P = 0.01), with no significant differences in cost. CONCLUSIONS A family-based social work intervention for children and adolescents who have deliberately poisoned themselves is as cost-effective as routine care alone.
Collapse
Affiliation(s)
- S Byford
- Centre for Health Economics, University of York.
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
The need to demonstrate the cost effectiveness of healthcare interventions has led to a rapid increase in the use of economic tools within pharmaceutical evaluations. Pharmacoeconomics is employed at many stages of the evaluation process, helping to predict which products are likely to be economically viable at an early stage, and providing information to aid price and reimbursement negotiations as well as formulary and purchasing decisions in conjunction with phase III and IV clinical trials. The ability of economic evaluations to accurately determine the best use of society's scarce resources, however, is strongly influenced by the existence of areas of confusion, controversy and dispute which hinder the researcher at every step. A good economic evaluation requires a number of ingredients including: (i) relevant, good quality clinical data, raising issues of trial design, sample size and perspective; (ii) relevant costs and outcomes, measured, valued and discounted credibly and accurately; (iii) appropriate methods of data analysis (statistical, incremental and sensitivity); and, once the trial is over, (iv) presentation of the results in a way which maximises the generalisability of the results and, hence, the usefulness of the research. None of these areas are trouble-free but with understanding and openness, mistakes can be minimised.
Collapse
Affiliation(s)
- S Byford
- Centre for Health Economics, University of York, England.
| | | |
Collapse
|
38
|
Affiliation(s)
- S Byford
- Centre for Health Economics, University of York, York YO1 5DD
| | | |
Collapse
|
39
|
Affiliation(s)
- S Byford
- Centre for Health Economics, University of York, Heslington, UK
| | | |
Collapse
|
40
|
Sculpher MJ, Dwyer N, Byford S, Stirrat GM. Randomised trial comparing hysterectomy and transcervical endometrial resection: effect on health related quality of life and costs two years after surgery. Br J Obstet Gynaecol 1996; 103:142-9. [PMID: 8616131 DOI: 10.1111/j.1471-0528.1996.tb09666.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare the impact of endometrial resection and abdominal hysterectomy on a range of health outcomes and health service costs, based on longer term follow up of patients randomised to a clinical trial. DESIGN A parallel group of randomised control trial. SETTING The gynaecology department of a teaching hospital. PARTICIPANTS 196 women requiring surgical treatment for menorrhagia were randomised and received surgery (88 underwent resection and 97 hysterectomy). Longer term follow up was undertaken using a postal questionnaire sent to all 196 women. MAIN OUTCOME MEASURES Longer term assessment was on the basis of menstrual symptoms, health related quality of life using the Short Form 36 (SF36) and the EuroQol visual analogue scale, patient satisfaction and health service resource cost. RESULTS Of 196 women who were sent a questionnaire, 155 (79%) responded at an average interval of 2.8 years after initial surgery. All aspects of health outcomes were as good or better in patients randomised to hysterectomy. Among patients randomised to resection, 57% had experienced no improvement in premenstrual symptoms following surgery and 23% had taken time off work due to menstrual problems; among hysterectomy patients, these rates were 23% and 4%, respectively. Women randomised to hysterectomy had better mean scores on seven of the eight dimensions of the SF36 health related quality of life instrument, with the greatest difference being on the pain dimension (P = 0.01). Women randomised to hysterectomy were generally more satisfied with treatment (P = 0.002). By two years after initial surgery, women randomised to resection had a 12% probability of having had a repeat resection and a 16% chance of having had a hysterectomy. As a percentage of the mean total cost associated with women randomised to hysterectomy, the mean total cost of resection was 53% based on four months follow up; this proportion had increased to 71%, based on an average overall follow up of 2.2 years. CONCLUSIONS These results show that, at an average follow up of 2.8 years among responders to a questionnaire, women randomised to hysterectomy experienced more of an improvement in menstrual symptoms and higher rates of satisfaction with treatment. There is also some evidence of superior health related quality of life amongst hysterectomy patients. However, the health service cost of endometrial resection remains lower than that of hysterectomy. An assessment of the relative cost effectiveness of the two procedures awaits further research.
Collapse
Affiliation(s)
- M J Sculpher
- Health Economics Research Group, Brunel University, Uxbridge, United Kingdom
| | | | | | | |
Collapse
|