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Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Declaration of interest
Six of the 16 authors have received royalties or fees for RO DBT. R.J.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from NIHR. T.R.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd and a grant outside the submitted work from the Medical Research Council. He was codirector of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two current directors of Radically Open Ltd. H.O’M. reports personal fees from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.C.R. provides RO DBT supervision through S C Rushbrook Ltd. I.T.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M.St. reports personal fees from British Isles DBT Training, Stanton Psychological Services Ltd, and Taylor & Francis Ltd. M.Sw. reports personal fees from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis Ltd. B.W. was codirector of Radically Open Ltd between November 2014 and February 2015.
Granular flows occur in a wide range of situations of practical interest to industry, in our natural environment and in our everyday lives. This paper focuses on granular flow in the so-called inertial regime, when the rheology is independent of the very large particle stiffness. Such flows have been modelled with the
-rheology, which postulates that the bulk friction coefficient
(i.e. the ratio of the shear stress to the pressure) and the solids volume fraction
are functions of the inertial number
only. Although the
-rheology has been validated in steady state against both experiments and discrete particle simulations in several different geometries, it has recently been shown that this theory is mathematically ill-posed in time-dependent problems. As a direct result, computations using this rheology may blow up exponentially, with a growth rate that tends to infinity as the discretization length tends to zero, as explicitly demonstrated in this paper for the first time. Such catastrophic instability due to ill-posedness is a common issue when developing new mathematical models and implies that either some important physics is missing or the model has not been properly formulated. In this paper an alternative to the
-rheology that does not suffer from such defects is proposed. In the framework of compressible
-dependent rheology (CIDR), new constitutive laws for the inertial regime are introduced; these match the well-established
relations in the steady-state limit and at the same time are well-posed for all deformations and all packing densities. Time-dependent numerical solutions of the resultant equations are performed to demonstrate that the new inertial CIDR model leads to numerical convergence towards physically realistic solutions that are supported by discrete element method simulations.
Telephone cognitive–behaviour therapy (TCBT) may be a cost-effective method for improving access to evidence-based treatment for obsessive–compulsive disorder (OCD) in young people.
Economic evaluation of TCBT compared with face-to-face CBT for OCD in young people.
Randomised non-inferiority trial comparing TCBT with face-to-face CBT for 72 young people (aged 11 to 18) with a diagnosis of OCD. Cost-effectiveness at 12-month follow-up was explored in terms of the primary clinical outcome (Children's Yale-Brown Obsessive-Compulsive Scale, CY-BOCS) and quality-adjusted life-years (QALYs) (trial registration: ISRCTN27070832).
Total health and social care costs were higher for face-to-face CBT (mean total cost £2965, s.d. = £1548) than TCBT (mean total cost £2475, s.d. = £1024) but this difference was non-significant (P = 0.118). There were no significant between-group differences in QALYs or the CY-BOCS and there was strong evidence to support the clinical non-inferiority of TCBT. Cost-effectiveness analysis suggests a 74% probability that face-to-face CBT is cost-effective compared with TCBT in terms of QALYs, but the result was less clear in terms of CY-BOCS, with TCBT being the preferred option at low levels of willingness to pay and the probability of either intervention being cost-effective at higher levels of willingness to pay being around 50%.
Although cost-effectiveness of TCBT was sensitive to the outcome measure used, TCBT should be considered a clinically non-inferior alternative when access to standard clinic-based CBT is limited, or when patient preference is expressed.
Declaration of interest
D.M.-C. reports research grants from the Swedish Research Council (Vetenskapsrådet), the Swedish Research Council for Health, working life and welfare (Forte), the US National Institute of Mental Health (NIMH), the UK National Institute of Health Research (NIHR), as well as royalties from Wolters Kluwer Health and Elsevier, all unrelated to the submitted work.
We sought to explore factors associated with depressive symptom severity among older persons (≥60 years of age) and to compare the depressive symptoms commonly experienced by older elderly (≥75 years) with those commonly experienced by younger elderly (<75 years).
Secondary analysis was conducted on data from a nationally representative survey.
Four parishes in Jamaica.
A total of 2,943 older community dwellers participated.
The survey included the Zung Self-rating Depression Scale (ZSDS), the Mini Mental State Examination (MMSE), and items on age, sex, and educational level. Linear regression analysis was used to determine the association between ZSDS score and: age, sex, MMSE score, and educational level. Logistic regression analysis was used to determine, for each ZSDS item, whether particular responses were more associated with older or younger elderly.
Higher ZSDS scores were associated with increasing age (B = 0.13, p < 0.001), lower MMSE score (B = −0.42, p < 0.001), the female sex (B = 3.52, p < 0.001), and lower educational level (B = −1.27, p < 0.001). The ZSDS items that were endorsed significantly more (p < 0.05) by older elderly related to negative evaluations about their functionality and value. Hopelessness was also more prominent among the older elderly. The items that were endorsed significantly more (p < 0.05) by the younger elderly had less of a focus.
Among older persons, increasing age was associated with marginally higher levels of depressive symptoms. Female gender, cognitive deficits, preoccupations about value and functionality, and feelings of hopelessness may serve as useful screening parameters.
To analyse publication and citations trends of case reports within otolaryngology – head and neck surgery literature, with specific attention to the most-cited reports.
Web of Science was searched for article type ‘case reports’ published in the leading otolaryngology – head and neck surgery journals since 1945. Variables including publication dates, citation dates and numbers, author, author number, and others were recorded and analysed for trends. The reports with the most citations (classics) were further studied.
Of nearly 67 000 published articles in leading otolaryngology – head and neck surgery journals, the overall number of case reports as a percentage of the total has substantially decreased over time. A total of 110 case report classics were identified for which citations have increased.
Although the case report may not be worthy of its tarnished record, declining trends in publication suggest a limited future for this valuable research and educational resource.
Objectives: Patient production losses occur when individuals’ capacities to work, whether paid or unpaid, are impaired by illness, treatment, disability, or death. There is controversy about whether and how to include patient production losses in economic evaluations in health care. Patient production losses have not previously been considered when evaluating medications for reimbursement under the U.K. National Health Service. Proposals for value-based assessment of health technologies in the United Kingdom created renewed interest in whether and how to include costs from a wider societal perspective, such as patient production losses, within economic evaluation of healthcare interventions.
Methods: A narrative review was undertaken of theoretical, ethical, and policy issues that might inform decisions that involve the normative question of whether or not to include patient production losses in economic evaluation.
Results: It seems difficult to reconcile the implications of including patient production losses with the objectives of a healthcare system dedicated to providing universal healthcare coverage without regard to patients’ ability to pay.
Conclusions: Tax payer funded healthcare systems may legitimately adopt maximands other than health gain, but these will be at the opportunity cost of less than maximum health gains.
The Galway Astronomical Stokes Polarimeter (GASP) is a high time resolution, full-Stokes imaging polarimeter which utilises a Fresnel rhomb prism as a beam-splitter and quarter wave retarder. The ability to perform optical photometry and polarimetry at high frame rates enables more detailed studies of a multitude of compact objects including; optical pulsars, magnetars and Active Galactic Nuclei (AGN). We present a brief discussion of the instruments’ current capabilities and hardware design. GASP is currently configured with two Electron Multiplying Charge-Coupled Devices (EMCCDs), which offer sub-millisecond frame readout speeds over a defined region of interest on the sensor. We will report results from an observational campaign at the William Herschel Telescope (WHT) in December, 2015. During this campaign GASP was used to study the Crab Pulsar, V404 Cygni and polarisation standards. As a subset of our analysis we have identified a significant contribution from the Interstellar Medium (ISM) and the interaction of a varying polarised source with the ISM, the subsequent conversion of linearly polarised light to circular, and its dependence on the angle of the source emission electric field orientation. Further to the presentation of results we will discuss future observational work, which is planned for September 2017 and subsequent improvements to increase the temporal resolution of the detectors.
Despite the early optical detection of the Crab pulsar in 1969, optical pulsars have become the poor cousin of the neutron star family. Only five normal pulsars have been observed to pulse in the optical waveband. A further three magnetars/SGRs have been detected in the optical/near IR. Optical pulsars are intrinsically faint with a first order luminosity, predicted by Pacini, to be proportional to P−10, where P is the pulsar’s period. Consequently they require both large telescopes, generally over-subscribed, and long exposure times, generally difficult to get. However optical observations have the benefit that polarisation and spectral observations are possible compared to X-ray and gamma-ray observations where polarisation measurements are limited. Over the next decade the number of optical pulsars should increase as optical detectors approach 100% quantum efficiency and as we move into the era of extremely large telescopes where limiting fluxes will be 30 to 100 times fainter compared to existing optical telescopes.
On a sufficiently soft substrate, a resting fluid droplet will cause significant deformation of the substrate. This deformation is driven by a combination of capillary forces at the contact line and the fluid pressure at the solid surface. These forces are balanced at the surface by the solid traction stress induced by the substrate deformation. Young's Law, which predicts the equilibrium contact angle of the droplet, also indicates an a priori radial force balance for rigid substrates, but not necessarily for soft substrates that deform under loading. It remains an open question whether the contact line transmits a non-zero force tangent to the substrate surface in addition to the conventional normal (vertical) force. We present an analytic Fourier transform solution technique that includes general interfacial energy conditions, which govern the contact angle of a 2D droplet. This includes evaluating the effect of gravity on the droplet shape in order to determine the correct fluid pressure at the substrate surface for larger droplets. Importantly, we find that in order to avoid a strain singularity at the contact line under a non-zero tangential contact line force, it is necessary to include a previously neglected horizontal traction boundary condition. To quantify the effects of the contact line and identify key quantities that will be experimentally accessible for testing the model, we evaluate solutions for the substrate surface displacement field as a function of Poisson's ratio and zero/non-zero tangential contact line forces.
The U.S.–Japan–Australia Trilateral Strategic Dialogue (TSD) was the first formal trilateral security mechanism in the Asia-Pacific, and one of the earliest and most important nodes of what former U.S. Secretary of Defense Ashton Carter calls the “principled security network” that the United States and its partners have been constructing in the region. Since it was established in 2002 the TSD has become institutionalized at the ministerial level and has met twice at the leaders’ level, becoming the most developed and substantial trilateral involving the United States in the Asia-Pacific. Augmented in 2007 by a Security and Defense Cooperation Forum involving defence as well as foreign ministry officials, the TSD has developed into a useful mechanism for coordinating policy positions on regional issues such as North Korea and the South China Sea, and for driving deeper strategic cooperation between the three countries in areas including defence, security, intelligence, development assistance, capacity building, and humanitarian assistance and disaster relief (HADR). It has also helped to foster stronger defence and security ties between Japan and Australia — the weakest leg of the strategic triangle.
The strategic logic of trilateral U.S.–Japan–Australia defence and security cooperation remains compelling. Threats to the United States and its allies in the Asia-Pacific are intensifying — whether from North Korea's nuclear weapons and ballistic missile programmes, China's assertiveness in the Western Pacific (increasingly backed by sophisticated area denial weapons), or the resurgence of Islamist terrorist networks in Southeast Asia. These threats will increasingly stretch the constrained resources of the United States and its allies. The only cost-effective way to remedy the ensuing capability gaps in key areas such as intelligence, surveillance, and reconnaissance (ISR), undersea warfare, missile defence, and amphibious lift is to develop greater interoperability and, ultimately, integration among U.S. and allied military forces. Japan and Australia are two of the United States’ most capable and dependable allies in the region, as well as longstanding economic and diplomatic partners, who over the past decade have been steadily building their own substantial bilateral strategic relationship. Moreover, their respective strategic geographies complement each other and the United States’ maritime strategy in the Indian Ocean and Asia-Pacific region. Current trilateral defence cooperation focuses heavily on combined exercises, with the three countries steadily increasing the frequency, scale, and sophistication of their three-way exercise programme.