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Treatment outcomes across Improving Access to Psychological Therapies (IAPT) services in England have improved year-on-year, with the national average proportion of patients in recovery at the end of treatment now exceeding the 50% target. This is despite the number of referrals and numbers of treated patients also increasing year-on-year, suggesting that services have evolved local practices and treatment delivery to meet needs whilst improving performance. This study explores whether there have been changes in clinical practice with regard to: (1) the number of sessions and length of treatments; (2) the number of cancellations and non-attendance; and (3) the recording of problem descriptor information, and the association with treatment outcomes in IAPT. Routinely collected data from seven IAPT services involved in the North and Central East London (NCEL) IAPT Service Improvement and Research Network (SIRN) were brought together to form a dataset of nearly 88,000 patients who completed a course of IAPT treatment. Results showed that there was a slight increase in the average number of sessions, and decreases in the length of time in treatment, as well as decreases in both the number of non-attended appointments and the use of inappropriate problem descriptors. These findings highlight a number of areas where potentially small changes to clinical practice may have had positive effects on patient outcomes. The value of using IAPT data to inform service improvement evaluations is discussed.
Key learning aims
(1) How changes to treatment-delivery factors are associated with IAPT patient outcomes.
(2) The link between clinical practice and potential service performance.
(3) How analysing routinely collected data can be used to inform service improvement.
Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated.
147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion.
The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.
DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.
In the Western and Central Pacific Ocean (WCPO), which accounts for over half of world
tuna production, purse seine effort and catch on floating objects have increased
significantly due to a rapid increase in the use of fixed and free-floating fish
aggregation devices (FADs). FAD fishing has had an impact on the current status of the
stocks of the three main target tunas in the equatorial WCPO, skipjack (Katsuwonus
pelamis), yellowfin (Thunnus albacares) and bigeye (T.
obesus). FADs have been shown to influence the behaviour and movement patterns
of the three tuna species with the juveniles of each species occupying shallower habitats
when associated with FADs. Aggregation of tunas around drifting objects increases their
vulnerability to purse seine gear, particularly for juvenile and small size classes.
Further to the impacts on the target stocks, the use of FADs has increased the
vulnerability of other fishes to the purse seine method, including some shark and billfish
species. Given the concern over FAD-related fishing effort on target and bycatch species,
there is a need to understand how FAD use affects target and bycatch stocks. Science needs
to better support management decisions are highlighted including the need to identify the
magnitude of broader community-level affects.
There is a wide international consensus that there is an urgent need to compile national inventories of animal genetic resources, supported by periodic monitoring of trends and threats, to underpin their effective management. This paper gives an overview of how to set about this task, primarily through national strategies but also through ad hoc surveys. It is important to establish stakeholder involvement at an early stage of setting up the national strategy so that the surveys can be made more effective and the emergent actions can be more readily implemented. There are a wide variety of tools available for surveying and monitoring, ranging from mapping expeditions to household surveys and censuses, encompassing methods associated with rapid rural appraisals. Tools have different strengths and weaknesses and their relative cost effectiveness will depend on objectives. Performing a baseline survey is a key step because it serves as a reference point for future monitoring; however, to be cost effective, more rudimentary surveys may be needed beforehand to establish reliable design parameters. Calibration of one method to another is an important task when several methods are being used for monitoring. Planning and design, communication, sensitive field work, data management and an analysis appropriate to the objectives are all necessary elements of a successful survey.
Aims – The use of specialised services to avoid admission to hospital for people experiencing mental health crises is seen as an integral part of psychiatric services in some countries. The aim of this paper is to assess the impact on costs and costeffectiveness of a crisis resolution team (CRT). Methods – Patients who were experiencing mental health crises sufficient for admission to be considered were randomised to either care provided by a CRT or standard services. The primary outcome measure was inpatient days over a six-month follow-up period. Service use was measured, costs calculated and cost-effectiveness assessed. Results – Patients receiving care from the CRT had non-inpatient costs £768 higher than patients receiving standard care (90% CI, £153 to £1375). With the inclusion of inpatient costs the costs for the CRT group were £2438 lower for the CRT group (90% CI, £937 to £3922). If one less day spent as an inpatient was valued at £100, there would be a 99.5% likelihood of the CRT being costeffective. Conclusion – This CRT was shown to be cost-effective for modest values placed on reductions in inpatient stays.
This paper assesses the economic impact of a crisis resolution team (CRT) in South London, using data from a prospective controlled trial. Two cohorts of patients were compared. After referral with a psychiatric crisis, the first cohort received existing services and the second cohort had access to input from a CRT. Baseline and follow-up 6-month costs were measured for 181 cases.
At follow-up, mean costs were £1681 less for the post-CRT patients, which was not statistically significant. However, a significant difference of £2189 was observed when patients with any CRT contact were compared with those with none.
The crisis resolution team resulted in lower costs. Such services can thus help to release funds for other forms of care.
Crisis resolution teams (CRTs) are being introduced throughout England, but their evidence base is limited.
To compare outcomes of crises before and after introduction of a CRT.
A new methodology was developed for identification and operational definition of crises. A quasi-experimental design was used to compare cohorts presenting just before and just after a CRT was established.
Following introduction of the CRT, the admission rate in the 6 weeks after a crisis fell from 71% to 49% (OR 0.38, 95% CI 0.21–0.70). A difference of 5.6 points (95% CI 2.0–8.3) on mean Client Satisfaction Questionnaire (CSQ–8) score favoured the CRT. These findings remained significant after adjustment for baseline differences. No clear difference emerged in involuntary hospitalisations, symptoms, social functioning or quality of life.
CRTs may prevent some admissions and patients prefer them, although other outcomes appear unchanged in the short term.
The world fame of Samuel Beckett is due to a combination of high academic esteem and immense popularity. An innovator in prose fiction to rival Joyce, his plays have been the most influential in modern theatre history. As an author in both English and French and a writer for the page and the stage, Beckett has been the focus for specialist treatment in each of his many guises, but there have been few attempts to provide a conspectus view. This book, first published in 1994, provides thirteen introductory essays on every aspect of Beckett's work, some paying particular attention to his most famous plays (e.g. Waiting for Godot and Endgame) and his prose fictions (e.g. the 'trilogy' and Murphy). Other essays tackle his radio and television drama, his theatre directing and his poetry, followed by more general issues such as Beckett's bilingualism and his relationship to the philosophers. Reference material is provided at the front and back of the book.
Les formes sont variées où l’immuable se soulage d’être sans forme.
Beckett could hardly perhaps have more perfectly exemplified Malone's dictum - 'The forms are many in which the unchanging seeks relief from its formlessness' - than by choosing both French and English as expressive mediums, and then translating from one to the other. In so strikingly hybridized a context even to speak of 'the English fiction' runs the risk of seeming simply a convenient construct ill-adapted to what is in reality, if not a confused, then at least a potentially confusing state of affairs. But even Beckett's extraordinary writing career began with due deference to the compromise of composing in his mother tongue, so that for all practical purposes there is a kind of logic in reserving 'the English fiction' for the body of work he produced before turning forty. The work in question comprises three novels - Murphy', Watt, and Dream of fair to middling women (the last to surface but the first to be written); three stories - Assumption, A case in a thousand and Echo's bones (none of them strictly part of the corpus as Beckett came to conceive it); a book of prose fiction that is not quite a novel and not quite a collection of short stories - More pricks than kicks; and a scatter of non-fictional items more or less ancillary to his narrative enterprises.