Sustained benefit of cognitive behaviour therapy for health anxiety in medical patients (CHAMP) over 8 years: a randomised-controlled trial

BACKGROUND

Health anxiety is an under-recognised but a frequent cause of distress. It is particularly common in general hospitals.

METHODS

We carried out an 8-year follow-up of medical out-patients with health anxiety (hypochondriasis) enrolled in a randomised-controlled trial in five general hospitals in London, Middlesex and Nottinghamshire. Randomisation was to a mean of six sessions of cognitive behaviour therapy adapted for health anxiety (CBT-HA) or to standard care in the clinics. The primary outcome was a change in score on the Short Health Anxiety Inventory, with generalised anxiety and depression as secondary outcomes. Of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics, 306 (68.9%) were followed-up 8 years after randomisation, including 36 who had died. The study is registered with controlled-trials.com, ISRCTN14565822.

RESULTS

There was a significant difference in the HAI score in favour of CBT-HA over standard care after 8 years [1.83, 95% confidence interval (CI) 0.25-3.40, p = 0.023], between group differences in generalised anxiety were less (0.54, 95% CI -0.29 to 1.36), p = 0.20, ns), but those for depression were greater at 8 years (1.22, 95% CI 0.42-2.01, p < 0.003) in CBT-HA than in standard care, most in standard care satisfying the criteria for clinical depression. Those seen by nurse therapists and in cardiology and gastrointestinal clinics achieved the greatest gains with CBT-HA, with greater improvement in both symptoms and social function.

CONCLUSIONS

CBT-HA is a highly long-term effective treatment for pathological health anxiety with long-term benefits. Standard care for health anxiety in medical clinics promotes depression. Nurse therapists are effective practitioners.

From inter-agency to multidisciplinary work in a sector generic mental health team

The effects of establishing a full multidisciplinary community psychiatric team in central London are described. The nature of referrals, and referrers' satisfaction with the service were examined during two comparable six-month periods, before and after the changes. The number and severity of referrals increased, and referrers were more satisfied with the new service. In contrast to the inter-agency model, the new multidisciplinary team was associated with more appropriate referral of those patients with the greatest need for specialist services. Clinical skill mix in the team and referrer education are the two factors most likely to have promoted these important changes. The key role of the psychiatrist in a full multidisciplinary team who can empower multi-professional case managers in their day-to-day management of severely ill patients is highlighted.

Controlled comparison of two crisis resolution and home treatment teams

Aims and method

To compare an existing crisis resolution service with a new crisis resolution team (CRT) in Wales. The impact of the new team was measured by changes in bed days and admissions. A random sample of patients from each service was assessed for service satisfaction, social functioning and quality of life after first presentation.

Results

The total number of bed days was reduced following the introduction of the new CRT (27.3%). The frequency and duration of compulsory admissions increased by 31% in the CRT between the first and second years and by 7% in the control service, offset by a greater reduction in informal admissions in the CRT (23.5%) compared with the control group (13.3%); overall bed usage was unchanged. Service satisfaction, social functioning and quality of life showed no important differences between the services.

Clinical implications

Crisis resolution teams may reduce informal admissions in the short term but at the cost of more compulsory admissions later.

Nidotherapy compared with enhanced care programme approach training for adults with aggressive challenging behaviour and intellectual disability (NIDABID): cluster-randomised controlled trial

BACKGROUND

Aggressive challenging behaviour is very common in care homes for people with intellectual disability, and better psychological treatments are needed. Nidotherapy aims to change the environment of people with mental illness and is an appropriate treatment for this group of disorders.

METHOD

The design was a cluster randomised trial of 20 care homes in which the staff either received training in nidotherapy or the enhanced care programme approach (ECPA), with equivalent duration of treatment in each arm. Cluster randomisation of care homes was carried out at the beginning of the study by an independent statistician. Primary and secondary outcomes were not specified exactly in view of absence of previous study data, but changes over time in scores on two scales, the Modified Overt Aggression Scale and the Problem Behaviour Check List were the main outcome measures. Serious violent incidents were recorded using the Quantification of Violence Scale. All these measures were recorded monthly by research assistants who were carefully kept blind to the allocation of treatment.

RESULTS

A total of 200 residents entered the trial, 115 allocated to the ECPA arm and 85 to the nidotherapy one. Seven residents left the care homes in the course of the study, and six were replaced; these were included 79 in the analysis as the trial was a pragmatic one. There were no material reductions in challenging behaviour in the first 8 months of the trial in either group, but in the last 7 months, those allocated to nidotherapy had a 33% reduction in Modified Overt Aggression Scale (MOAS) scores and a 43% reduction in Problem Behaviour Check List scores compared with 5% and 13%, respectively, for the ECPA group, differences which for the MOAS were close to statistical significance.

DISCUSSION

Nidotherapy shows promise in the management of aggressive challenging behaviour in care homes, but a delay in its benefit might be expected if given to staff only. The treatment is worthy of further evaluation and development.

Prevalence and service implications of health anxiety in genitourinary medicine clinics

A comparison of the prevalence of health anxiety in genitourinary medicine (GUM) clinics in two UK centres was carried out using a new rating scale, the Health Anxiety Inventory (HAI). The relationship of health anxiety to demographic and clinical variables, and its impact on service contacts, was also examined in one of these centres. 694 patients were assessed and significant health anxiety was identified in 8–11%. HAI scores were stable over time and high levels persisted in the absence of treatment. Attenders with sexually transmitted infections had significantly lower levels of health anxiety than those with other conditions. Contacts with clinic doctors and health advisors in the nine months before and after assessment were significantly greater in those with high health anxiety, with doctor appointments 37% higher in the high HAI group ( P = 0.005). Health anxiety is a source of considerable morbidity in GUM clinics deserving further study.

Prevalence of aggressive challenging behaviours in intellectual disability and its relationship to personality status: Jamaican study

BACKGROUND

Both the classification of personality disorder in intellectual disability (ID) and its identification in practice are deemed to be difficult. A simpler approach to classification and its relationship to challenging behaviours were tested in an adult Jamaican population with ID.

METHOD

The study was carried out in Kingston, Jamaica, as part of a programme of field trials to determine the utility of the proposed revision of personality disorders in the 11th Revision of the International Classification of Diseases (ICD-11), in a population of adults with ID living with their families or in supported care homes. Thirty-eight people with borderline (n = 5), mild (n = 16), moderate (n = 14) and severe (n = 3) ID were assessed at face-to-face interview and with relatives or staff using the provisional criteria for severity of personality disorder and its associated domain traits, and challenging behaviour was assessed using the Problem Behaviour Check List (PBCL) (a 5-point, 7-item scale).

RESULTS

Using the severity scale 18 patients (47%) had no personality disorder, 7 (18%) had personality difficulty, 9 (24%) had mild personality disorder, and 4 (11%) had moderate personality disorder. None of the sample had severe personality disorder in which there is high risk of harm to self or others. Of the four major trait domains, provisionally named anankastic, detached, emotional and dissocial, three were evenly distributed in those with personality disturbance with the antagonistic (antisocial) trait less commonly shown (6 only). Scores on the PBCL were higher in those with increasing severity of personality disorder (P = 0.03) and those in the antagonistic personality trait domain had the highest PCL scores.

CONCLUSIONS

Despite previous difficulties in assessing personality disorder in intellectual difficulties the ICD-11 classification was easy to administer in practice in this population, and the higher problem behaviour scores in those with greater severity of personality disturbance support its construct validity.

Ethnicity as a predictor of detention under the Mental Health Act

BACKGROUND

There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for.

METHOD

Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments - either resulting in 'detention' or 'no detention'.

RESULTS

Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention.

CONCLUSIONS

There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

Criminal offending before and after the onset of psychosis: examination of an offender typology

OBJECTIVE

Clinicians often consider whether or not offenders with psychosis have a history of offending pre-dating the onset of their illness. The typology of offenders based on age at first offence, developed in the field of criminology, has been recently extended to mentally disordered groups, but this ignores the potential role of illness onset.

METHOD

Using a large UK cohort of individuals with both psychosis and offending histories (n=331), we compared those with a history of offending pre-dating their illness (pre-morbid offenders) to those who commenced offending after becoming unwell (post-morbid offenders). We compared the demographic, clinical and offending pattern characteristics of the two groups.

RESULTS

198 (60%) had offended before the onset of psychosis. These pre-morbid offenders were more likely to be male, have a lower pre-morbid IQ and have had a history of neurological abnormality. Pre-morbid offenders also committed more crime overall, but this was due to an excess of acquisitive, drug and minor offending, rather than violent offending, which was comparable to the post-morbid offending group.

CONCLUSION

Currently, standardised clinical risk assessment tools view offenders with mental illness as a homogenous group with respect to life-course patterns of offending in relation to illness. Taking account of an individual's pathway to offending may improve risk assessment and management.

Group art therapy as an adjunctive treatment for people with schizophrenia: a randomised controlled trial (MATISSE)

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.

The 5/95 gap in the indexation of psychiatric journals of low- and middle-income countries

OBJECTIVE

To investigate the relationship between science production and the indexation level of low- and middle-income countries (LAMIC) journals in international databases.

METHOD

Indicators of productivity in research were based on the number of articles produced over the 1994-2004 period. A survey in both Medline and ISI/Thomson was conducted to identify journals according to their country of origin. A WPA Task Force designed a collaborative process to assess distribution and quality of non-indexed LAMIC journals.

RESULTS

Twenty LAMIC were found to present more than 100 publications and a total of 222 indexed psychiatric journals were found, but only nine were from LAMIC. The Task Force received 26 questionnaires from editors of non-indexed journals, and concluded that five journals would meet criteria for indexation.

CONCLUSION

Barriers to indexation of journals contribute to the difficulties in achieving fair representation in the main literature databases for the scientific production in these countries.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities

BACKGROUND

Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base.

METHOD

A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo.

RESULTS

The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited.

CONCLUSIONS

Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a randomised controlled trial (NACHBID)

OBJECTIVE(S)

To assess the effects and cost-effectiveness of haloperidol, risperidone and placebo on aggressive challenging behaviour in adults with intellectual disability.

DESIGN

A double-blind randomised controlled trial of two drugs and placebo administered in flexible dosage, with full, independent assessments of aggressive and aberrant behaviour, global improvement, carer burden, quality of life and adverse drug effects at baseline, 4, 12 and 26 weeks, and comparison of total care costs in the 6 months before and after randomisation. At 12 weeks, patients were given the option of leaving the trial or continuing until 26 weeks. Assessments of observed aggression were also carried out with key workers at weekly intervals throughout the trial.

SETTING

Patients were recruited from all those being treated by intellectual disability services in eight sites in England, one in Wales and one in Queensland, Australia.

PARTICIPANTS

Patients from all severity levels of intellectual disability; recruitment was extended to include those who may have been treated with neuroleptic drugs in the past.

EXCLUSION CRITERIA

treatment with depot neuroleptics/another form of injected neuroleptic medication within the last 3 months; continuous oral neuroleptic medication within the last week; those under a section of the Mental Health Act 1983 or Queensland Mental Health Act 2000.

INTERVENTIONS

Randomisation to treatment with haloperidol (a typical neuroleptic drug), risperidone (an atypical neuroleptic drug) or placebo using a permuted blocks procedure. Dosages were: haloperidol 1.25-5.0 mg daily; risperidone 0.5-2.0 mg daily.

MAIN OUTCOME MEASURES

Primary: reduction in aggressive episodes between baseline and 4 weeks using Modified Overt Aggression Scale. Secondary: Aberrant Behaviour Checklist; Uplift/Burden Scale; 40-item Quality of Life Questionnaire; Udvalg for Kliniske Undersøgelser scale; Clinical Global Impressions scale. Economic costs recorded using a modified version of Client Service Receipt Inventory for 6 months before and after randomisation.

RESULTS

There were considerable difficulties in recruitment because of ethical and consent doubts. Twenty-two clinicians recruited a total of 86 patients. Mean daily dosages were 1.07 mg rising to 1.78 mg for risperidone and 2.54 mg rising to 2.94 mg for haloperidol. Aggression declined dramatically with all three treatments by 4 weeks, with placebo showing the greatest reduction (79%, versus 57% for combined drugs) (p = 0.06). Placebo-treated patients showed no evidence of inferior response in comparison to patients receiving neuroleptic drugs. An additional study found that clinicians who had not participated in clinical trials before were less likely to recruit. Mean total cost of accommodation, services, informal care and treatment over the 6 months of the trial was 16,336 pounds for placebo, 17,626 pounds for haloperidol and 18,954 pounds for risperidone.

CONCLUSIONS

There were no significant important benefits conferred by treatment with risperidone or haloperidol, and treatment with these drugs was not cost-effective. While neuroleptic drugs may be of value in the treatment of aggressive behaviour in some patients with intellectual disability, the underlying pathology needs to be evaluated before these are given. The specific diagnostic indications for such treatment require further investigation. Prescription of low doses of neuroleptic drugs in intellectual disability on the grounds of greater responsiveness and greater liability to adverse effects also needs to be re-examined.

The treatment of challenging behaviour in intellectual disabilities: cost-effectiveness analysis

BACKGROUND

Antipsychotic drugs are used in the routine treatment of adults with intellectual disabilities (ID) and challenging behaviour in the UK despite limited evidence of their effectiveness. There is no evidence on their cost-effectiveness.

METHODS

The relative cost-effectiveness of risperidone, haloperidol and placebo in treating individuals with an ID and challenging behaviour was compared from a societal perspective in a 26-week, double-blind, randomised controlled trial. Outcomes were changes in aggression and quality of life. Costs measured all service impacts and unpaid caregiver inputs.

RESULTS

After 26 weeks, patients randomised to placebo had lower costs compared with those in the risperidone and haloperidol treatment groups. Aggression was highest for patients treated with risperidone and lowest for patients treated with haloperidol; however, quality of life was lowest for patients treated with haloperidol and highest for patients treated with risperidone.

CONCLUSION

The treatment of challenging behaviour in ID with antipsychotic drugs is not a cost-effective option.

Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: an exploratory randomized controlled trial

BACKGROUND

Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive.

METHOD

This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning.

RESULTS

The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others.

CONCLUSIONS

CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group.

Engagement and retention in specialist services for people with personality disorder

OBJECTIVE

To quantify levels of engagement and retention in specialist services for people with personality disorder (PD).

METHOD

Demographic and clinical data were collected on referrals to 10 specialist services for people with PD. Follow-up data on retention and drop-out from services were collected over the following 30 months.

RESULTS

Seven hundred and thirteen (60.1%) of 1186 people referred to services were taken by them, of whom 164 (23.0%) subsequently dropped out prior to the completion of an episode of care. Men, younger people and those with higher levels of personality disturbance were less likely to complete a package of care.

CONCLUSION

Specialist community-based services for adults with PD are able to engage most of those that are referred to them, but further efforts need to be made to find ways to engage younger people and men with PD.

The 5/95 Gap on the dissemination of mental health research: The World Psychiatric Association (WPA) task force report on project with editors of low and middle income (LAMI) countries

The World Psychiatric Association (WPA) Task Force and a small group previously convened by the WPA publications committee initiated three activities between 2006-2008 that aimed to respond to the need for greater support for psychiatry journals in LAMI countries. In a joint venture with participants from the Global Mental Health Movement the Task Force editors from LAMI countries in Africa, Asia, Eastern Europe and Latin America were contacted to identify potential journals to target for indexation (Medline and ISI). The committee analyzed the editors' applications on the following criteria: a) geographical representativeness; b) affiliation to a professional mental health society; c) regular publication of at least 4 issues per year over the past few years; d) comprehensive national and international editorial boards; e) publication of original articles, or at least abstracts, in English; f) some level of current indexation; g) evidence of a good balance between original and review articles in publications; and h) a friendly access website. The committee received 26 applications (11 from Latin America, 7 from Central Europe, 4 from Asia and 4 from Africa), and selected 8 journals, 2 from each geographical area, on the basis of the overall scores obtained for the items mentioned, to participate in an editors meeting held in Prague in September 2008. The aims of the committee are twofold: a) to concentrate support for those selected journals; and b) to assist all LAMI mental health editors in improving the quality of their journals and fulfilling the requirements for full indexation. This report summarizes the procedures conducted by the committee, the assessment of the current non-indexed journals, and offers suggestions for further action.

Community mental health teams for people with severe mental illnesses and disordered personality

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favor of providing care in a variety of nonhospital settings, underpins the rationale behind care in the community. A major thrust toward community care has been the development of community mental health teams.

The prevalence of personality disorder in schizophrenia and psychotic disorders: systematic review of rates and explanatory modelling

BACKGROUND

Personality disorder (PD) in psychosis is poorly studied. As PD can affect outcome in mental disorders, it is important to understand its prevalence in order to plan services, understand prognosis more fully and maximize management options. MethodLiterature searching revealed 3972 potential papers. Twenty papers including 6345 patients were included in the final analysis. There was great variation in prevalence and multilevel modelling was used to identify possible reasons for this heterogeneity.

RESULTS

The prevalence of PD varied from 4.5% to 100%. Multilevel analysis suggested country of study, study type, the instruments used to diagnose PD and patient care correlated with the prevalence data explaining the study level heterogeneity, with 34.2, 33.4, 17.0 and 4.5% by each variable respectively. Personality studies in Canada and Sweden reported lower PD prevalence, whereas in Spain it was higher than the multinational study. Compared with randomized controlled trials, case-control studies reported lower prevalence [odds ratio (OR)=0.35, 95% confidence interval (CI) 0.15-0.79] and observational studies higher prevalence (OR 70.5, 95% CI 8.5-583). Primary-care patients were less likely to be diagnosed (OR 0.02, 95% CI 0-0.19) than hospital patients, and out-patients had higher prevalence (OR 12.5, 95% CI 1.77-88.6).

CONCLUSIONS

The reported prevalence of PD in schizophrenia varies significantly. Statistical modelling suggests care, country, study type and diagnostic tools for PD all bias prevalence rates. The number of papers reaching the inclusion criteria, the relative paucity of information and the difficulties in developing an accurate statistical model limited interpretation from the study.

Predictors of violent victimization amongst those with psychosis

OBJECTIVE

The aim of this study was to establish the prevalence and predictors of violent victimization amongst a community-dwelling sample of individuals with psychosis.

METHOD

The 2-year prevalence of self-reported violent victimization was estimated for a sample of 708 individuals with chronic psychosis living in the community in four urban UK centres. Baseline socio-demographic and clinical factors were examined as possible risk factors for victimization over the 2-year follow-up period.

RESULTS

The 2-year prevalence of violent victimization in the sample was 23%. Four factors were found to be independently predictive of victimization - history of victimization, less than daily family contact, young age at illness onset and the presence of co-morbid Cluster B personality disorder.

CONCLUSION

Those with psychotic illnesses are at elevated risk of being assaulted. Given the likely adverse health implications, clinicians should routinely enquire about victimization in their assessments of those with psychotic disorders particularly amongst those who are socially isolated, with a younger age of illness onset and in those with co-morbid personality disorder.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

SEARCH STRATEGY

We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

We included all randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

MAIN RESULTS

CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.

AUTHORS' CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

[Improving the publication rate of Spanish researchers in good journals]

Five obstacles are described that currently prevent Spanish researchers in the psychological sciences from publishing more frequently in journals of high impact factor. These are: a) a general lack of confidence in your ability; b) a tendency for your papers to be driven more by speculation rather than data; c) excessive length of submitted manuscripts; d) higher than expected rates of drop-out and non-participation in studies, and e) lack of independence from pharmaceutical companies. Although many of these problems will require long-term structural changes, others can be addressed immediately and yield improvement rapidly.

Do care patterns change over time in a newly established mental health service? A report from the UK700 trial

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.

The Nottingham study of neurotic disorder: predictors of 12 year costs

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.

Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey

BACKGROUND

Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England.

METHOD

We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16-74 years, living in private households in England.

RESULTS

Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups.

CONCLUSIONS

Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

Randomized controlled trial of assertive community treatment in intellectual disability: the TACTILD study

BACKGROUND

There has been a policy shift away from hospital to community in the services of all those with psychiatric disorders, including those with intellectual disability (ID), in the last 50 years. This has been accompanied recently by the growth of assertive outreach services, but these have not been evaluated in ID services.

METHOD

In a randomized controlled trial we compared assertive outreach with 'standard' community care, using global assessment of function (GAF) as the primary outcome measure, and burden and quality of life as secondary measures.

RESULTS

We recruited 30 patients, considerably less than expected; no significant differences were found between the primary and secondary outcomes in the two groups. The differences were so small that a Type II error was unlikely.

CONCLUSIONS

Reasons for this lack of specific efficacy of the assertive approach are discussed and it is suggested that there is a blurring of the differences between standard and assertive approaches in practice.

Temporal reliability of psychological assessments for patients in a special hospital with severe personality disorder: a preliminary note

BACKGROUND

The new programme for assessing those with dangerous and severe personality disorder relies heavily on psychological assessments of personality disorder and risk.

METHODS

The temporal reliability of assessments of psychopathy (PCL-R), risk (HCR-20) and personality was assessed using the International Personality Disorder Examination (IPDE) in 15 randomly selected male prisoners in a high secure hospital carried out at intervals varying between a mean of nine and 19 months after initial assessments by a variety of assessors.

RESULTS

Using the intra-class correlation coefficient the agreement varied between 0.57 (HCR-20), 0.58 (PCL-R) and 0.38-0.70 for IPDE personality disorders, with the best agreement for antisocial personality disorder (0.70).

COMMENT

These levels of agreement are consistent with other recent work on temporal reliability of personality instruments but are a little too low for confidence in these measures alone in the assessment process.

Therapist competence and clinical outcome in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial: the POPMACT study

BACKGROUND

Therapist competence may be an important factor in determining clinical outcome in psychological therapies. However, there are few published studies of therapist competence v. patient outcome from randomized controlled trials. We tested the hypothesis that higher levels of therapist competence would lead to better clinical outcomes in both patient- and observer-rated measures at 6- and 12-month follow-up.

METHOD

A random sample of 49 audiotapes of manual assisted cognitive therapy sessions delivered by 21 therapists involved in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial was rated to assess the level of therapist competence. Patient outcome was assessed using self and observer ratings of depressive and anxiety symptoms, social functioning, global functioning and number of episodes of deliberate self-harm.

RESULTS

At 6-month follow-up, there was a statistically significant association between therapist level of competence and observer-rated depression only. At 12-month follow-up, significant associations were noted between therapist competence and all observer-rated clinical outcomes but not for self-rated outcome measures. However, there was no association between therapist competence and the number of self-harm episodes during follow-up.

CONCLUSIONS

When treated by therapists rated as more competent than other therapists who received equivalent brief training, patients with recurrent self-harm show significant clinical improvements. However, this benefit is not identified across all outcome measures and is not fully apparent until 12-month follow-up.

Persistent social dysfunction in anxious and depressed patients with personality disorder

OBJECTIVE

To determine the long-term social function of psychiatric patients with anxiety and depressive disorders and to relate this to personality status and other factors.

METHOD

A cohort of 210 patients (mean age 35 years) with dysthymic disorder, generalized anxiety disorder or panic disorder diagnosed using a structured interview (SCID) were assessed at baseline for personality status using the Personality Assessment Schedule (PAS) and ratings of anxiety and depression. Exactly 12 years later social function was assessed using the Social Functioning Questionnaire (SFQ) and personality reassessed with the PAS by a rater blind to initial personality status. Individual social function items were examined in those with and without personality disorders.

RESULTS

Social function was significantly better in those with little or no baseline personality disturbance (P < 0.001) and the domains of close relationships, stress in completing tasks, use of spare time and family relationships showed the largest personality differences. A multiple linear regression model showed that self-rated depression scores, single marital status and personality status were the main baseline variables predicting social function at 12 years.

CONCLUSION

Although personality characteristics may change over time social dysfunction persists and persistent social dysfunction in mental state disorders may be a strong indicator of personality disturbance rather than an indicator of treatment resistance.

Comorbidity of substance misuse and mental illness in community mental health and substance misuse services

BACKGROUND

Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.

AIMS

To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.

METHOD

Cross-sectional prevalence survey in four urban UK centres.

RESULTS

Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.

CONCLUSIONS

Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach

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.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

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.

"Cold calling" in psychiatric follow up studies: is it justified?

BACKGROUND

The ethics of cold calling-visiting subjects at home without prior appointment agreed-in follow up research studies has received little attention although it is perceived to be quite common. We examined the ethical implications of cold calling in a study of subjects with defined neurotic disorders followed up 12 years after initial assessment carried out to determine outcome in terms of symptoms, social functioning, and contact with health services. The patients concerned were asked at original assessment if they would agree to be followed up subsequently and although they agreed no time limit was put on this.

OBJECTIVES

To decide if cold calling was ethically justifiable and, if so, to set guidelines for researchers.

DESIGN

The study was a cohort study of patients with neurotic disorder treated initially for 10 weeks in a randomised controlled trial.

FINDINGS

At follow up by a research medical practitioner 18 of the 210 patients had died and of the remaining 192 patients 186 (97%) were seen or had a telephone interview. Four patients refused and two others did not have interviews but agreed to some data being obtained. However, only 104 patients (54%) responded to letters inviting them to make an appointment or to refuse contact and the remainder were followed up by cold calling, with most patients agreeing readily to the research interview. The findings illustrate the dilemma of the need to get the maximum possible data from such studies to achieve scientific validity (and thereby justify the ethics of the study) and the protection of subjects' privacy and autonomy.

CONCLUSIONS

More attention needs to be paid to consent procedures if cold calling is to be defended on ethical grounds but it is unreasonable to expect this to be obtained at the beginning of a research study in a way that satisfies the requirements for informed consent. A suggested way forward is to obtain written consent for the research at the time that cold calling takes place before beginning the research.

Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis?

OBJECTIVE

To examine the association between co-morbid personality disorder (PD) and suicidal behaviour over a 2-year period in a sample of patients with psychosis.

METHOD

A total of 670 patients with established psychotic illness were interviewed using a battery of instruments including a screen for co-morbid PD. The prevalence of attempted and completed suicide was measured over the next 2 years using multiple data sources. Logistic regression was used to examine whether those with co-morbid PD were at greater risk of suicidal behaviour compared with others.

RESULTS

One hundred and eighty six patients (28%) were rated as having a co-morbid PD. After adjusting for all covariates, patients with co-morbid PD were significantly more likely to attempt or complete suicide over the 2-year period (adjusted odds ratio: 1.87; 95% CI: 1.02-3.42).

CONCLUSION

Co-morbid PD is independently associated with an increased risk of suicidal behaviour in psychosis. Early assessment of personality status should be part of the routine assessment of all psychiatric patients.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

OBJECTIVE

To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

METHOD

A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK).

RESULTS

Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI.

CONCLUSION

While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

The effect of alcohol consumption on cost of care in severe psychotic illness: a report from the UK700 study

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.

The measurement of engagement in the homeless mentally ill: the Homeless Engagement and Acceptance Scale--HEAS

BACKGROUND

Much of the difficulty in helping the homeless mentally ill arises as a consequence of their resistance to engagement. A refused intervention can seldom influence a client's problems and engagement status can be argued as being an important independent predictor of outcome. No instrument could be identified which systematically measured the factors involved. This paper describes the development and psychometric properties of a new scale, the Homeless Engagement and Acceptance Scale (HEAS).

METHOD

Staff from an established project for the homeless mentally ill helped to identify relevant questions used to develop a five-item rating scale for completion by an informant. After piloting, the instrument was tested in a study in which subjects were assessed twice over 12 months by informants. Item analysis was undertaken and predictive validity was assessed.

RESULTS

Item analysis indicated a good facility index signifying all items were able to differentiate subjects according to the characteristic being measured, and a high discrimination index demonstrating that all items were measuring the same concept. Predictive validity and internal consistency coefficients were both good. The 3 month HEAS score was found to be a significant predictor of accommodation status and adequacy of a support network at 12 months.

CONCLUSIONS

The good psychometric properties and predictive validity of the scale suggest the HEAS is likely to be a useful tool in assessing engagement status. One of the five questions (Q4) can be omitted for those who are not homeless and the scale termed the Engagement and Acceptance Scale (EAS).

A randomised controlled trial of enhanced key-worker liaison psychiatry in general practice

BACKGROUND

Despite much interest in the development of liaison psychiatry in general practice there is no clear evidence that any form of intervention is effective. We carried out a pilot randomised controlled trial, the first we believe into this type of care, of one such model; enhanced liaison with individual patients by key workers, in general practices in Paddington and North Kensington in London.

METHODS

All patients referred from primary to secondary psychiatric care from four general practices over a 10-month period, and still in contact with services, were eligible to be included in the study. The practices were allocated in a constrained randomised procedure to either normal care or enhanced key-worker liaison. The latter involved encouraging individual key workers to adopt improved communication between primary and secondary care. Baseline assessments of symptomatology and social functioning were made before randomisation and after 6 months by an independent researcher.

RESULTS

Of the 84 eligible patients, 43 were seen at baseline and 34 re-assessed after 6 months. There was no difference between the clinical outcomes in the two groups but self-rated social function was significantly improved in the enhanced liaison service compared with standard care (adjusted P = 0.05). Costs were similar but somewhat more expensive for enhanced liaison. Less than half (42 %) of all key workers in the enhanced liaison arm felt they had involved the primary health care team more in the care of their patient, with 21 % of these altering their practice markedly during the study.

CONCLUSIONS

It is concluded that without additional resources enhanced key-worker liaison for psychiatry in primary and secondary care has limited benefits although this does not necessarily apply to other forms of liaison practice.

Difficulties in conducting a randomized controlled trial of health service interventions in intellectual disability: implications for evidence-based practice

BACKGROUND

In an era of evidence-based medicine, practice is constantly monitored for quality in accordance with the needs of clinical governance (Oyebode et al. 1999). This is likely to lead to a dramatic change in the treatment of those with intellectual disability (ID), in which evidence for effective intervention is limited for much that happens in ordinary practice. As Fraser (2000, p. 10) has commented, the word that best explains "the transformation of learning disability practice in the past 30 years is 'enlightenment'." This is not enough to satisfy the demands of evidence, and Fraser exhorted us to embrace more research-based practice in a subject that has previously escaped randomized controlled trials (RCTs) of treatment because of ethical concerns over capacity and consent, which constitute a denial of opportunity which "is now at last regarded as disenfranchising".

CONCLUSIONS

The present paper describes the difficulties encountered in setting up a RCT of a common intervention, i.e. assertive community treatment, and concludes that a fundamental change in attitudes to health service research in ID is needed if proper evaluation is to prosper.

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough

BACKGROUND

Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group.

METHODS

The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years.

RESULTS

Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups.

CONCLUSIONS

Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.