Why care about integrated care? Part I. Demographics, finances and workforce: immovable objects facing mental health services

Demands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.

Impact of secondary care financial incentives on the quality of physical healthcare for people with psychosis: a longitudinal controlled study

BACKGROUND

Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive.

AIMS

To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis.

METHOD

Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening.

RESULTS

Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37-20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33-10.10).

CONCLUSIONS

The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.

Unleashing talent in mental health sciences: gender equality at the top

Society is undergoing a shift in gender politics. Science and medicine are part of this conversation, not least as women's representation and pay continue to drop as one progresses through more senior academic and clinical levels. Naming and redressing these inequalities needs to be a priority for us all.Declaration of interestNone.

Delivery of Psychiatric Care

This paper proposes criteria essential for the effective delivery of psychiatric care and briefly reviews the extent to which they are fulfilled by current services. An audit study is described where district general practitioners were asked to evaluate the extent to which their local psychiatric services met their needs and those of their patients. The implications for the development of community psychiatric services is discussed.

Patient access to Psychiatric Records: The Patients’ View

The passing of legislation relating to subject access to personal health data has been accompanied by concern about the possible harmful effects of this development on patients. Despite the lack of substantive evidence psychiatric patients have been regarded as the group most at risk. This study investigates the subjective views of patients on access to records on two psychiatric wards.

On learning from the patient: hearing voices

This paper presents the coping strategies developed by one patient with 18 years experience of managing her own schizophrenic illness. The interventions which evolved gave her significant control over her illness. We report her experiences and emphasise that for some patients with treatment resistant schizophrenia, the patients themselves may have expertise in managing their symptoms.

Improving treatment adherence among patients with chronic psychoses

This paper presents the literature on compliance as an ideology and then examines strategies to improve patient outcomes if non-compliance is identified as undermining the treatment regimen. We present strategies used by our team in a south London rehabilitation service for the severely mentally ill.

The one-day census in clinical audit

Psychiatric care is delivered by a wide range of workers (psychiatrists, hospital nurses, community psychiatric nurses, occupational therapists, psychologists, social workers, counsellors and general practitioners) who work as teams with some patients and as individuals with others. Health authority resources for psychiatric care are widely distributed among facilities both hospital-based (wards, day hospitals, out-patient departments, social work departments, occupational therapy departments) and community-based (community psychiatric nursing departments, community mental health centres and facilities funded jointly with social services and voluntary agencies).

Establishing psychiatric attachments to general practice: a six stage plan

Since the 1970s there has been a growing trend for psychiatrists to establish formal attachments to primary care and these now form an important component of community psychiatry (Strathdee & Williams, 1984). In this paper a six stage plan for the establishment of a psychiatric attachment is proposed. The framework outlined may be modified in the light of local service, training and research needs.

The case for catchment areas for mental health services

The establishment of mental health teams which take responsibility for small geographical catchment areas has been a fundamental element in the planning of community services in most Western European countries over the last decade. This idea is challenged in the companion paper in this issue of Psychiatric Bulletin which refers to catchment areas as a “relic of the past”. The case is put for catchment areas in terms of their planning, service delivery and quality advantages for the development of comprehensive inter-agency mental health services. In brief, it is argued that community mental health services are still in many areas poorly developed (Audit Commission, 1994; Faulkner et al, 1994), and that catchment areas are necessary but not sufficient for their fuller realisation.

Progress on NICE guideline implementation in mental health trusts: meta-analyses

Aims and Method

To investigate implementation of National Institute for Health and Clinical Excellence (NICE) guidelines in mental health, focusing on the schizophrenia guideline. Data analyses centred on implementation of the guideline, as well as looking at a set of markers mapped to the NICE principles of implementation and other identified clinical prerequisites. A self-report questionnaire tool was sent to senior executives at mental health trusts containing questions linked to the markers of implementation and clinical prerequisites; responses were analysed with data from the Healthcare Commission audit of implementation of the guideline to show key relationships.

Results

Information from both data-sets (senior executive data collection and the audit) showed that implementation is patchy, with pockets of good implementation. Findings indicate that higher levels of implementation are linked to corporate commitment and leadership, as well as support from commissioners.

Clinical Implications

Implementation might be improved by corporate commitment and leadership and better support from commissioners.

Making a reality of user involvement in community mental health services

User centred services as an ideology have not become a reality of everyday clinical practice. In this paper we introduce a series of articles which describe user centred practice in a south London community-based rehabilitation service for the severely mentally ill. We emphasise the medical consultation style adopted, the service management style and specific initiatives allowing users to influence our practice and shape functional and structural components of the service.

Carrots and Sticks on Opposite Sides of the Atlantic: Integration Incentives for People With Serious Mental Illness in England

Integrating care pathways between primary and specialist mental health care is seen as integral to improving the health of people with mental illness. Multiple integration initiatives have been implemented, but few have tried to integrate care for people with serious mental illness. This column describes two such initiatives in the United States and in England. The two schemes are compared according to the population they target, payment mechanisms, accountability structures, service delivery, outcomes, and lessons learned.

Early life trauma, depression and the glucocorticoid receptor gene--an epigenetic perspective

BACKGROUND

Hopes to identify genetic susceptibility loci accounting for the heritability seen in unipolar depression have not been fully realized. Family history remains the 'gold standard' for both risk stratification and prognosis in complex phenotypes such as depression. Meanwhile, the physiological mechanisms underlying life-event triggers for depression remain opaque. Epigenetics, comprising heritable changes in gene expression other than alterations of the nucleotide sequence, may offer a way to deepen our understanding of the aetiology and pathophysiology of unipolar depression and optimize treatments. A heuristic target for exploring the relevance of epigenetic changes in unipolar depression is the hypothalamic-pituitary-adrenal (HPA) axis. The glucocorticoid receptor (GR) gene (NR3C1) has been found to be susceptible to epigenetic modification, specifically DNA methylation, in the context of environmental stress such as early life trauma, which is an established risk for depression later in life.

METHOD

In this paper we discuss the progress that has been made by studies that have investigated the relationship between depression, early trauma, the HPA axis and the NR3C1 gene. Difficulties with the design of these studies are also explored.

RESULTS

Future efforts will need to comprehensively address epigenetic natural histories at the population, tissue, cell and gene levels. The complex interactions between the epigenome, genome and environment, as well as ongoing nosological difficulties, also pose significant challenges.

CONCLUSIONS

The work that has been done so far is nevertheless encouraging and suggests potential mechanistic and biomarker roles for differential DNA methylation patterns in NR3C1 as well as novel therapeutic targets.

Screening for cognitive functioning in psychiatric outpatients with schizophrenia, alcohol dependence, and dual diagnosis

Cognitive impairment is common to both schizophrenia and alcoholism. Despite increasing recognition that people with both disorders represent a problematic client group, little is known about the possible additive effect of a dual diagnosis upon impaired cognitive function. This study investigates impairment of cognitive functioning in patients with schizophrenia, alcohol dependence, or a dual diagnosis of schizophrenia and alcohol use disorder. It was hypothesised that patients with dual diagnosis would show greater cognitive impairment than those with a single diagnosis. The Mini-Mental State Examination (MMSE) and standardised measures of psychiatric health and substance use were administered to 120 community psychiatric patients with a diagnosis of schizophrenia, alcohol dependence and both conditions (dual diagnosis). Higher rates of cognitive impairment were found among dual diagnosis patients compared to the schizophrenia or alcohol patients. This was shown in age-adjusted measures of global functioning, and on the tests of language, reading and writing, and visuospatial construction. Despite its common usage, global MMSE scores were insensitive to the cognitive impairments typically found in these clinical groups. Where the MMSE is used as a screening tool, it is recommended that scores are adjusted for the effects of age.

Control of gene expression by CpG island methylation in normal cells

The role of DNA methylation in the control of mammalian gene expression has been the subject of intensive research in recent years, partly due to the critical role of CpG island methylation in the inactivation of tumour suppressor genes during the development of cancer. However, this research has also helped elucidate the role that DNA methylation plays in normal cells. At present, it is also clear that DNA methylation forms an important part of the normal cell-regulatory processes that govern gene transcription. Methylation, targeted at CpG islands, is an important part of the mechanisms that govern X-chromosome inactivation; it is also essential for the maintenance of imprinted genes and, at least in some cases, is critical in determining the cell-type-specific expression patterns of genes. Study of these examples will be important in identifying the mechanisms that control targeting of DNA methylation and how these processes are disrupted during disease pathogenesis.

CpG-island methylation and epigenetic control of resistance to chemotherapy

Aberrant methylation of CpG islands (CpG-rich regions of DNA associated with the promoters of many genes) is associated with transcriptional inactivation of genes involved in tumour development. Genes involved in key DNA damage response pathways, such as cell-cycle control, apoptosis signalling and DNA repair can frequently become epigenetically silenced and methylated in tumours. This may lead to differences in intrinsic sensitivity of tumours to chemotherapy, depending on the specific function of the gene inactivated. Furthermore, chemotherapy itself may exert a selective pressure on epigenetically silenced drug sensitivity genes present in subpopulations of cells, leading to acquired chemoresistance. Clinical trials of epigenetic therapies are now in progress, and epigenetic profiling using DNA methylation will provide guidance on optimization of the use of these therapies with conventional chemotherapy, as well as helping to identify patient populations who may particularly benefit from such approaches.

Drug deaths in police custody: is dual diagnosis a significant factor?

This study examined cases for possible mental health issues based on a study of 43 deaths in custody that had been supervised by the PCA between 1998 and 2002 involving the use of drugs. In 18 of the 43 cases, there was evidence of one of three groups of mental health symptoms--in five cases, there was evidence of psychosis, in five of previous self-harm or suicidal attempts, and in a further eight, there were indications of anxiety or depression. This constitutes a total of 42% of the cases studied. Those with mental health factors were more likely to have swallowed the drugs used, were more likely to have used prescription drugs and were more likely to have been believed to be faking their symptoms by the officers involved in these cases. While it is recognised that mental health problems are widespread in the criminal justice system, the diversity of conditions and the marked overlap with the use of alcohol and illicit drugs has not been sufficiently recognised, either in the training of officers or in the procedures for intervention in the custody suite.

Cell type-specific methylation of an intronic CpG island controls expression of the MCJ gene

Over 50% of human genes are associated with CpG islands and DNA methylation within such CpG islands has been clearly correlated with inhibition of expression. Whereas changes in DNA methylation play a key role in a number of human diseases, in particular cancer, in normal DNA CpG islands are nearly always methylation free, regardless of the expression status of the associated gene. Only limited evidence supports a role for DNA methylation in controlling tissue-specific expression in adult somatic tissue. Loss of expression of the MCJ gene has previously been linked to increased chemotherapeutic drug resistance in ovarian cancer. We report that loss of expression of MCJ in drug-resistant ovarian cancer cell lines depends on methylation of a CpG island within its first exon, but is independent of methylation within the promoter region. Furthermore, cell type-specific expression of the MCJ gene in normal cells also depends on the methylation status of the CpG island within its first exon. The MCJ CpG island is methylated and the gene is not expressed in cells of epithelial origin, but unmethylated and expressed in cells of lymphocyte or fibroblast origin. Chromatin immunoprecipitation assays determined that MCJ CpG island methylation was associated with loss of histone acetylation in ovarian epithelial cells compared with unmethylated fibroblast cells. Reduced acetylation was observed not only within the CpG island, but also within the promoter region, suggesting that CpG island methylation may direct alterations in chromatin structure within the promoter region, leading to gene inactivation.

Threshold 2: the reliability, validity and sensitivity to change of the Threshold Assessment Grid (TAG)

OBJECTIVE

This study investigated the psychometric properties of the Threshold Assessment Grid (TAG), a new assessment of the severity of mental health problems.

METHOD

A total of 605 patients were recruited from 10 mental health adult and elderly services in London, UK. TAG ratings and other standardized definitions of severe mental illness were completed by referrers. TAG, Global Assessment of Functioning (GAF), Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) and Health of the Nation Outcome Scale (HoNOS) ratings were completed by mental health service staff. Construct validation on extreme groups was investigated.

RESULTS

Construct and concurrent validity were good. Referrer TAG scores predicted mental health team view of referral suitability, but not whether assessments were offered. Test-retest reliability was good, interrater reliability ranged from good to poor in different domains (but adequate for total TAG score), internal consistency was appropriate. Sensitivity to change requires further investigation.

CONCLUSION

The TAG can be recommended for use by all agencies when making referrals to mental health services.

Aberrant DNA methylation in cancer: potential clinical interventions

DNA methylation, the addition of a methyl group to the carbon-5 position of cytosine residues, is the only common covalent modification of human DNA and occurs almost exclusively at cytosines that are followed immediately by a guanine (so-called CpG dinucleotides). The bulk of the genome displays a clear depletion of CpG dinucleotides, and those that are present are nearly always methylated. By contrast, small stretches of DNA, known as CpG islands, are comparatively rich in CpG nucleotides and are nearly always free of methylation. These CpG islands are frequently located within the promoter regions of human genes, and methylation within the islands has been shown to be associated with transcriptional inactivation of the corresponding gene. Alterations in DNA methylation might be pivotal in the development of most cancers. In recent years, it has become apparent that the pattern of DNA methylation observed in cancer generally shows a dramatic shift compared with that of normal tissue. Although cancers often exhibit clear reductions throughout their genomes in the levels of DNA methylation, this goes hand-in-hand with increased methylation at the CpG islands. Such changes in methylation have a central role in tumourigenesis; in particular, methylation of CpG islands has been shown to be important in transcriptional repression of numerous genes that function to prevent tumour growth or development. Studies of DNA methylation in cancer have thus opened up new opportunities for diagnosis, prognosis and ultimately treatment of human tumours.

Threshold 3: the feasibility of the Threshold Assessment Grid (TAG) for routine assessment of the severity of mental health problems

BACKGROUND

Evidence-based practice requires the development of measures which are suitable for everyday clinical use ('feasible'). There is no consensus as to how to establish feasibility.

METHOD

The feasibility of a new assessment - the Threshold Assessment Grid (TAG) - for use when making referrals to mental health services was tested by training mental health teams in using the TAG and other standardised assessments, asking referrers to ten mental health services in London also to complete a TAG, surveying TAG users, and evaluating a feedback meeting at which TAG data were presented.

RESULTS

One hundred and one (61%) mental health staff received training, and 445 (74%) referrers of 600 patients completed TAGs. Sixty-five (65%) questionnaires from TAG users were completed, and 24 (80%) people attending feedback meetings evaluated the TAG. These allowed the extent to which the TAG is brief, simple, relevant, acceptable, available and valuable to be investigated.

CONCLUSION

The TAG exhibited good feasibility when used by mental health staff, and moderate feasibility when used by referrers. This approach can be used to investigate the feasibility of other standardised assessments.

A role for mismatch repair in control of DNA ploidy following DNA damage

Many reports have shown a link between mismatch repair (MMR) deficiency and loss of normal cell cycle control, particularly loss of G2 arrest. However almost all of these studies utilized transformed cell lines, and thus the involvement of other genes in this phenotype cannot be excluded. We have examined the effects of cisplatin treatment on primary embryo fibroblasts (MEFs) derived from mice in which the MMR gene Msh2 had been inactivated (Msh2(-/-)). This analysis determined that both primary Msh2(-/-) and wild type (WT) fibroblasts exhibited an essentially identical G2 arrest following cisplatin treatment. Similarly, we observed a cisplatin-induced G2 arrest in immortalized MMR deficient (Mlh1(-/-) and Pms2(-/-)) and WT MEFs. p53 deficient primary MEFs (p53(-/-)) exhibited both a clear G2 arrest and an increase in cells with a DNA content of 8N in response to cisplatin. When the Msh2 and p53 defects were combined (p53(-/-)/Msh2(-/-)) the G2 arrest was essentially identical to the p53(-/-) fibroblasts. However, the p53(-/-)/Msh2(-/-) fibroblasts demonstrated a further increase in cells with an 8N DNA content, above that seen in the p53(-/-) fibroblasts. These results suggest that loss of MMR on its own is not enough to overcome G2 arrest following exposure to cisplatin but does play a role in preventing polyploidization, or aberrant DNA reduplication, in the absence of functional p53.

Primary ovarian carcinomas display multiple methylator phenotypes involving known tumor suppressor genes

Mounting evidence suggests that aberrant methylation of CpG islands is a major pathway leading to the inactivation of tumor suppressor genes and the development of cancer. Recent studies on colorectal and gastric cancer have defined a CpG island methylator phenotype (CIMP), which involves the targeting of multiple genes by promoter hypermethylation. To determine the role of methylation in ovarian cancer, we have investigated the methylation status of 93 primary ovarian tumors at ten loci using methylation-specific polymerase chain reaction (MSP). Seven of the loci (BRCA1, HIC1, MINT25, MINT31, MLH1, p73 and hTR) were found to be methylated in a significant proportion of the ovarian tumors, and methylation of at least one of these was found in the majority (71%) of samples. Although concurrent methylation of multiple genes was commonly seen, this did not seem to be due to a single CIMP phenotype. Instead the results suggest the presence of at least three groups of tumors, two CIMP-positive groups, each susceptible to methylation of a different subset of genes, and a further group of tumors not susceptible to CpG island methylation, at least at the loci studied.

Reversal of drug resistance in human tumor xenografts by 2'-deoxy-5-azacytidine-induced demethylation of the hMLH1 gene promoter

Loss of DNA mismatch repair because of hypermethylation of the hMLH1 gene promoter occurs at a high frequency in a number of human tumors. A role for loss of mismatch repair (MMR) in resistance to a number of clinically important anticancer drugs has been shown. We have investigated whether the demethylating agent 2'-deoxy-5-azacytidine (DAC) can be used in vivo to sensitize MMR-deficient, drug-resistant ovarian (A2780/cp70) and colon (SW48) tumor xenografts that are MLH1 negative because of gene promoter hypermethylation. Treatment of tumor-bearing mice with the demethylating agent DAC at a nontoxic dose induces MLH1 expression. Re-expression of MLH1 is associated with a decrease in hMLH1 gene promoter methylation. DAC treatment alone has no effect on the growth rate of the tumors. However, DAC treatment sensitizes the xenografts to cisplatin, carboplatin, temozolomide, and epirubicin. Sensitization is comparable with that obtained by reintroduction of the hMLH1 gene by chromosome 3 transfer. Consistent with loss of MMR having no effect on sensitivity in vitro to Taxol, DAC treatment has no effect on the Taxol sensitivity of the xenografts. DAC treatment does not sensitize xenografts of HCT116, which lacks MMR because of hMLH1 mutation. Because there is emerging data on the role of loss of MMR in clinical drug resistance, DAC could have a role in increasing the efficacy of chemotherapy for patients whose tumors lack MLH1 expression because of hMLH1 promoter methylation.

Threshold Assessment Grid (TAG): the development of a valid and brief scale to assess the severity of mental illness

BACKGROUND

Lack of consensus about the meaning of severe mental illness makes it difficult to prioritise the severely mentally ill for specialist mental health care. The goal of this study was to develop a valid and brief assessment of severity of mental illness.

METHOD

Six search workshops (n = 57) using consensus techniques developed a draft assessment acceptable to users, carers, practitioners and policy makers. A two-round Delphi consultation (n = 58) was held to identify consensus on this instrument.

RESULTS

Search workshops agreed seven domains relevant to identifying the severely mentally ill: intentional and unintentional self-harm, risk from and to others, and survival, psychological, and social needs and disabilities. The Delphi consultation indicated at least agreement with all aspects in both rounds.

CONCLUSIONS

The Threshold Assessment Grid (TAG) is a brief method of identifying the severely mentally ill, which has adequate face, concurrent, construct and content validity.

A role for methylation of the hMLH1 promoter in loss of hMLH1 expression and drug resistance in ovarian cancer

Experimental evidence from several sources has identified a link between mismatch repair deficiency and cytotoxic drug resistance. Selection for cisplatin resistance in the human ovarian cancer cell line A2780, results in loss of expression of the mismatch repair protein hMLH1 in most (90%) of the resultant cisplatin-resistant cell lines. Here we demonstrate that the cisplatin sensitive parental cell line displays methylation of the promoter of only one hMLH1 allele, but that the resistant cell lines all exhibit hyper-methylation of the promoters of both hMLH1 alleles. Full methylation of all sites tested was found to be invariably associated with loss of hMLH1 expression, whereas a partial increase in methylation appears compatible with either loss or maintenance of expression. In addition treatment of two of the resistant cell lines with 5-azacytidine, a known inhibitor of methylation, results in re-expression of hMLH1. Clonogenic assays demonstrate that the 5-azacytidine treated cells show increased sensitivity to cisplatin. Furthermore, 12.5% (3/ 24) of ovarian tumours show hypermethylation of the hMLH1 promoter. Expression of hMLH1 is absent in the tumours that are hypermethylated, while all the unmethylated tumours still express the protein. This analysis suggests that methylation of the hMLH1 promoter may be a common mechanism for loss of hMLH1 expression, and possibly for cisplatin-resistance, in ovarian cancer.

Analysis of the CAVEOLIN-1 gene at human chromosome 7q31.1 in primary tumours and tumour-derived cell lines

We identified CAVEOLIN-1 as a candidate for a tumour suppressor gene mapping to human chromosome 7q31.1. A number of studies suggest that caveolin could function as a tumour suppressor. Expression of caveolin, and in turn the number of caveolae within a cell, are inversely correlated with the transforming ability of numerous oncoproteins, including H-ras, v-abl, and bcr-abl, and caveolin is a major transformation-dependent substrate of v-src. Heterologous expression of caveolin has been shown to abrogate anchorage-independent growth and induce apoptosis in transformed fibroblasts and also to suppress anchorage-independent growth in human mammary carcinoma cells. We have analysed the status and expression of the human CAVEOLIN-1 gene in primary tumours and tumour-derived cell lines. We found no evidence for mutation of CAVEOLIN-1 in human cancers. Additionally, we found that while the first two exons of CAVEOLIN-1 are associated with a CpG island, this is not methylated in either primary tumours or in tumour-derived cell lines in which Caveolin-1 expression is low or undetectable. The level of expression of Caveolin-1 does not correlate with loss of heterozygosity at the CAVEOLIN-1 locus in these same cell lines. Contrary to other published studies, we have shown that CAVEOLIN-1 is not expressed in normal breast ductal epithelial cells in vivo. CAVEOLIN-1 is however highly expressed in breast myoepithelial cells and its expression is retained in tumours derived from breast myoepithelium. Together our data refute a role for CAVEOLIN-1 as a breast tumour suppressor gene in vivo.

Rationale and design. PRiSM Psychosis Study I

BACKGROUND

This paper sets out the rationale for the PRiSM Psychosis Study, and the research design used. Nine accompanying papers present the main results. The questions addressed by the PRiSM Psychosis Study are: can the gains of experimental studies which have demonstrated benefits arising from treatment by community mental health teams be translated to routine settings? If so, are the benefits diluted in ordinary clinical practice? What are the costs?

METHOD

A prospective nonrandomised controlled trial of two types of community mental health service, in two phases: case identification followed by patient interviews. For the case identification the research team conducted the complete ascertainment of all prevalent cases of psychosis in the two study catchment areas in the index year (1991-1992). From all 514 patients with psychotic disorders thus identified, 302 were randomly allocated for interview, along with a key informant clinician and a carer. Interviews were under taken at two time points, two years apart.

RESULTS

This paper presents the socio-demographic, clinical and ethnic characteristics of the patients.

CONCLUSIONS

The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified.

Sexual and relationship problems amongst patients with severe chronic psychoses

Recent studies have begun to examine the complexity and frequency of sexual and relationship problems amongst samples of community resident people with severe psychoses. For the purposes of this study, subjects with severe persistent psychoses and under the care of a single community team were interviewed using a semi-structured clinical interview and structured diagnostic interview of marital and sexual satisfaction. Functional disability was assessed by the Multnomah Community Ability Scale. Amongst those interviewed (n = 53) the prevalence of sexual difficulties was 47.5% and 30.8% for men (n = 40) and women (n = 13), respectively. The majority of men (82.5%) and some of the women (38.5%) were not in intimate relationships; 42.5% of men and 38.5% of women had never had a sexual relationship. Amongst community resident patients with severe psychoses, the level of unmet need for specific interventions (including assessment procedures, psychotherapeutic, pharmaco-therapeutic) for sexual and relationship dysfunction is high. This warrants evaluation of service structures and treatment packages tailored for this group.

Current approaches to identifying the severely mentally ill

Mental health care is expensive to provide and resources should be targeted. Possible approaches to such a prioritization are outlined. In the United Kingdom, care is to be provided on the basis of need. The key issue is then identifying the severely mentally ill, who are most in need of mental health care. Definitions of severe mental illness used in research studies are reviewed, indicating a lack of consensus about identifying this group. Current practice in England was surveyed, by obtaining written documentation from 20 agencies on the eligibility criteria they use for deciding whether someone should receive mental health care. Government departments, user groups and professional bodies were also surveyed. The findings indicate that definitions of severe mental illness use the five dimensions of safety, informal and formal support, diagnosis, disability and duration--the SIDDD dimensions. These dimensions offer a framework for developing definitions of severe mental illness at the local level, thereby identifying the priority group for mental health care.

Molecular characterization of patients with 18q23 deletions

The 18q- syndrome is a deletion syndrome that is characterized by mental retardation, hearing loss, midfacial hypoplasia, growth deficiency, and limb anomalies. Most patients with this syndrome have deletions from 18q21-qter. We report on three patients with deletions of 18q23. A mother and daughter with identical deletions of 18q23 have many of the typical features of the 18q- syndrome, including midfacial hypoplasia and hearing loss. In contrast, the third patient has few of the symptoms of the 18q- syndrome. A contig of the 18q23 region was generated to aid in the mapping of the breakpoints. FISH was used to map both breakpoints to the same YAC clone. Furthermore, somatic-cell hybrids from the daughter and the third patient were isolated. The mapping results of sequence-tagged sites relative to the two breakpoints were identical, suggesting that the two deletion breakpoints map very close to one another. The analyses of these patients demonstrate that the critical region for the 18q- syndrome maps to 18q23 but that a deletion of 18q23 does not always lead to the clinical features associated with the syndrome. These patients demonstrate the wide phenotypic variability associated with deletions of 18q.

Neuropsychiatry of 18q- syndrome

Our understanding of neuropsychiatric abnormalities in patients with deletions of the long arm of chromosome 18 (18q- syndrome) is based mainly on sporadic case reports. We characterized the neuropsychiatric phenotype in 27 patients across a wide age range (2-47 years) with breakpoints ranging from 18q22.3-18q21.2. Adaptive behavior scores (Vineland Composite) were significantly higher in females than in males (62 +/- 5 vs. 43 +/- 3). Intelligence ranged from borderline to severely deficient (IQ, 73- < 40), with academic achievement similarly impaired. Performance in specific neuropsychological functions, including attention, novel problem solving, memory, language, visuomotor integration, and fine motor dexterity, was consistently in the moderately-to-severely impaired range. Behavioral problems were common in both sexes, including aggressivity, hyperactivity, and temper tantrums. Contrary to the few previous reports, we found no evidence of psychosis in any patients. In a subset of patients selected on the basis of no prior knowledge of behavioral problems, 1 of 16 patients (6%) had autism, as defined by the Autistic Diagnostic Interview--Revised (ADI-R) [Lord et al., 1994: J Autism Dev Disord 24:659-685]. Thus, the prevalence of autism in 18q- syndrome is probably no greater than that in other developmental disabilities with a similar level of cognitive impairment. In contrast to what has been believed since 18q- was first described 30 years ago, we found no relationship between chromosome deletion size and any measure of cognition or behavior; nor were there any correlations between any of these measures with the presence or absence of abnormalities on MRI or somatosensory-evoked potentials.

Ablepharon macrostomia syndrome with associated cutis laxa: possible localization to 18q

The ablepharon-macrostomia (AMS) and Barber-Say syndromes (BSS) are rare disorders characterized by absence of the eyelids or ectropion, macrostomia, ambiguous genitalia, abnormal ears, rudimentary nipples, and dry, redundant skin. Patients with Barber-Say syndrome also have hypertrichosis. We present a patient with a phenotype similar to AMS who has a complex rearrangement of chromosome 18, involving both an inversion and interstitial deletion. Our patient lacks the typical features of the 18q deletion syndrome. We review AMS and BSS as compared with our patient, and recognize cutis laxa as a feature shared by all. We propose that the gene(s) for this phenotype may lie on chromosome 18 in the region of the deletion or inversion breakpoints.

A new deletion of 18q23 with few typical features of the 18q- syndrome

We report on a patient with a deletion of 18q23. At both 2 and 4 years of age, she displayed few of the facial features or other clinical features associated with the 18q- syndrome. Fluorescent in situ hybridisation and microsatellite marker and RFLP analysis were performed to characterise the extent of the deletion, and a terminal deletion of 18q23 was confirmed. The deleted region includes the gene for myelin basic protein, suggesting that hemizygosity of this gene does not invariably lead to mental and developmental delay. The clinical presentation of this patient suggests that either she is not deleted for the genes involved in the 18q- clinical phenotype or this patient represents one end of the spectrum of the clinical variability seen with 18q terminal deletions.

Analysis of clinical variation seen in patients with 18q terminal deletions

Twenty-six patients with deletions of 18q were analyzed at the clinical and molecular levels in an attempt to delineate regions of chromosome 18 important to the 18q- syndrome phenotype. Molecular cytogenetic analysis was carried out using fluorescence in situ hybridization (FISH), and deletions ranging from 18q21.1-qter to 18q22.3-qter were detected. The parental origin of the deletions was determined by the analysis of inheritance of microsatellite markers. No correlation between size, parental origin, or severity of the resulting phenotype was found. The results suggest that a critical region for 18q- syndrome lies in the most distal portion of 18q and that it confers susceptibility for the various clinical manifestations of the 18q- syndrome when present in one copy.

The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness

BACKGROUND

People with severe mental illness often have a complex mixture of clinical and social needs. The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs. There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool. The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services.

METHOD

A draft version of the instrument was designed by the authors. Modifications were made following comments from mental health experts and a patient survey. Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument.

RESULTS

The mean number of needs identified per patient ranged from 7.55 to 8.64. Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 0.99 and 0.78 respectively. The percentage of complete agreement on individual items ranged from 100-81.6% (inter-rater) and 100-58.1% (test-retest).

CONCLUSIONS

The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness. It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes.