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There is an absence of instruments to assess the complex needs of pregnant women and mothers with severe mental illness. We aimed to develop a standardised assessment of need for pregnant women and mothers with severe mental illness.
Staff and service users identified relevant domains of need. Professional experts and service users were then surveyed and asked to rate the importance of the domains of the CAN-M (Camberwell Assessment of Need – Mothers). Reliability was established using 36 service user-staff pairs. Concurrent validity was assessed with the Global Assessment of Functioning.
Inter-rater and test-retest reliability coefficients for unmet needs indicated excellent reliability. Relevant CAN-M domains correlated with the Global Assessment of Functioning symptom (p=0.05) and disability (p <0.01) subscales.
The CAN-M is a reliable, valid instrument for assessing the needs of pregnant women and mothers with severe mental illness.
An ‘advance statement’ allows a patient to state treatment preferences in anticipation of a time in the future when, as a result of a mental disorder or disability, he or she may no longer be able to make treatment decisions. A number of types of advance statements in psychiatry can be described: ‘advance directives’ (and ‘facilitated advance directives’), ‘crisis cards’ and ‘joint crisis plans’. They differ according to a number of characteristics – the degree to which they have legal force, whether the clinical team is involved in their formulation, and whether a third party acts as a facilitator. There is accumulating evidence that some forms of advance statement empower patients and reduce the need for coercive treatments. The results of a randomized controlled trial of ‘joint crisis plans’ carried out by our research team in SE England will be discussed. A significant reduction in compulsory admissions to hospital was an important finding.
This study aimed to evaluate whether a pre-operative elevated serum alkaline phosphatase level is a potential predictor of post-operative hypocalcaemia after total thyroidectomy.
Data was retrospectively collected from the case notes of patients who had undergone total thyroidectomy. Patients were divided into Graves’ disease and non-Graves’ groups. Pre-operative and post-operative biochemical markers, including serum calcium, alkaline phosphatase and parathyroid hormone levels, were reviewed.
A total of 225 patients met the inclusion criteria. Graves’ disease was the most common indication (n = 134; 59.5 per cent) for thyroidectomy. Post-operative hypocalcaemia developed in 48 patients (21.3 per cent) and raised pre-operative serum alkaline phosphatase was noted in 94 patients (41.8 per cent). Raised pre-operative serum alkaline phosphatase was significantly associated with post-operative hypocalcaemia, particularly in Graves’ disease patients (p< 0.05).
Pre-operative serum alkaline phosphatase measurements help to predict post-thyroidectomy hypocalcaemia, especially in patients who do not develop hypoparathyroidism. Ascertaining the pre-operative serum alkaline phosphatase level in patients undergoing total thyroidectomy may help surgeons to identify at-risk patients.
Depression and anxiety are major causes of absence from work and underperformance in the workplace. Cognitive behavioural therapy (CBT) can be effective in treating such problems and online versions offer many practical advantages. The aim of the study was to investigate the effectiveness of a computerized CBT intervention (MoodGYM) in a workplace context.
The study was a phase III two-arm, parallel randomized controlled trial whose main outcome was total score on the Work and Social Adjustment Scale (WSAS). Depression, anxiety, psychological functioning, costs and acceptability of the online process were also measured. Most data were collected online for 637 participants at baseline, 359 at 6 weeks marking the end of the intervention and 251 participants at 12 weeks post-baseline.
In both experimental and control groups depression scores improved over 6 weeks but attrition was high. There was no evidence for a difference in the average treatment effect of MoodGYM on the WSAS, nor for a difference in any of the secondary outcomes.
This study found no evidence that MoodGYM was superior to informational websites in terms of psychological outcomes or service use, although improvement to subthreshold levels of depression was seen in nearly half the patients in both groups.
Risk assessment is now regarded as a necessary competence in psychiatry. The area under the curve (AUC) statistic of the receiver operating characteristic curve is increasingly offered as the main evidence for accuracy of risk assessment instruments. But, even a highly statistically significant AUC is of limited value in clinical practice.
We aimed at testing whether an assertive outreach team (AOT) run by a Black voluntary organisation is more acceptable to Black people with severe mental illness.
A randomised controlled trial (RCT) of 83 Black (African, African Caribbean or Black British) patients with severe mental illness with treatment as usual (TAU) or Assertive Outreach (AO) by a non-statutory sector Black AOT. Frequency of admissions, duration of admissions, symptom severity and client satisfaction with clinical interventions were assessed.
The mean length of admission at follow-up was not significantly different between the two groups (74.64 v. 64.51; mean difference = 10.13, 95% CI −2.86, 23.11, p = 0.125), neither was the mean number of admissions (1.32 v. 1.20; mean difference = 0.13, 95% CI −0.18, 0.43, p = 0.401). Mean Brief Psychiatric Rating Scale (BPRS) ratings at 1-year follow-up were significantly lower in the AOT group than in the TAU group (56.34 v. 63.62; mean difference = 7.27, 95% CI 0.66, 13.88, p = 0.032), and people were significantly more satisfied with AOT 24/29 (83%) than the generic services: 4/26 (15%), p < 0.001.
While the AO service was highly culturally acceptable to Black people, there was no evidence that the provision of AOT reduces frequency or duration of hospital admission.
To investigate the utilisation of bone-anchored hearing aids and Softband, as well as the effects on quality of life, amongst the paediatric and young adult population of Freeman Hospital, Newcastle Upon Tyne, UK.
Retrospective, anonymised, cross-sectional survey using the Glasgow Benefit Inventory and Listening Situation Questionnaire (parent version), administered at least three months following the start of bone-anchored hearing aid or Softband use.
One hundred and nine patients were included, of whom syndromic children made up a significant proportion (22 of 109). Patients using bone-anchored hearing aids obtained significant educational and social benefit from their aids. The mean Listening Situation Questionnaire difficulty score was 17 (15 patients), which is below the trigger score of 22+ at which further reassessment and rehabilitation is required. 87% (of 15 patients) did not require further intervention. The overall mean GBI score for the 22 patients (syndromic and non-syndromic) was +29.
The use of bone-anchored hearing aids and Softband results in significant improvements in quality of life for children and young adults with hearing impairment. There is significant under-utilisation of bone-anchored hearing aids in children with skull and congenital abnormalities, and we would advocate bone-anchored hearing aid implantation for these patients.
Key questions regarding residential alternatives to standard acute psychiatric care, such as crisis houses and short-stay in-patient units, concern the role that they fulfil within local acute care systems, and whether they manage people with needs and illnesses of comparable severity to those admitted to standard acute wards.
To study the extent to which people admitted to residential alternatives and to standard acute services are similar, and the role within local acute care systems of admission to an alternative service.
Our approach combined quantitative and qualitative methods. Consecutive cohorts of patients in six residential alternatives across England and six standard acute wards in the same areas were identified, and clinical and demographic characteristics, severity of symptoms, impairments and risks compared. Semi-structured interviews with key stakeholders in each local service system were used to explore the role and functioning of each alternative.
Being already known to services (OR = 2.6, 95% CI 1.3–5.2), posing a lower risk to others (OR = 0.49, 95% CI 0.31–0.78) and having initiated help-seeking in the current crisis (OR = 2.2, 95% CI 1.2–4.3) were associated with being admitted to an alternative rather than a standard service. Stakeholder interviews suggested that alternatives have a role that is similar but not identical to standard hospital services. They can divert some, but not all, patients from acute admission.
Residential alternatives are integrated into catchment area mental health systems. They serve similar, but not identical, clinical populations to standard acute wards and provide some, but not all, of the functions of these wards.
Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards.
To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP–RCT) design (ISRCTN20804014).
We used a PP–RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission.
Forty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (randomised or preference arms), but women who obtained their preferred intervention were more satisfied with treatment.
Although the sample sizes were too small to allow definite conclusions, the results suggest that when services are able to provide interventions preferred by patients, those patients are more likely to be satisfied with treatment. This pilot study provides some evidence that women's crisis houses are as effective as traditional psychiatric wards, and may be more cost-effective.
Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched.
To explore short-term outcomes and costs of admission to alternative and standard services.
Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services.
All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12–2.86), TAG (difference 1.40, 95% CI 0.39–2.51) and GAF functioning (difference 4.15, 95% CI 1.08–7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK£3832 v. £9850). Standard services cost an additional £2939 per unit HoNOS improvement.
The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.
Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched.
To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction.
Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored.
No significant difference was found in intensity of staff– patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives.
Similarities in care may be more marked than differences at alternative and standard services. Staff–patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.
There is evidence from North American trials that supported employment using the individual placement and support (IPS) model is effective in helping individuals with severe mental illness gain competitive employment. There have been few trials in other parts of the world.
To investigate the effectiveness and cost-effectiveness of IPS in the UK.
Individuals with severe mental illness in South London were randomised to IPS or local traditional vocational services (treatment as usual) (ISRCTN96677673).
Two hundred and nineteen participants were randomised, and 90% assessed 1 year later. There were no significant differences between the treatment as usual and intervention groups in obtaining competitive employment (13% in the intervention group and 7% in controls; risk ratio 1.35, 95% CI 0.95–1.93, P = 0.15), nor in secondary outcomes.
There was no evidence that IPS was of significant benefit in achieving competitive employment for individuals in South London at 1-year follow-up, which may reflect suboptimal implementation. Implementation of IPS can be challenging in the UK context where IPS is not structurally integrated with mental health services, and economic disincentives may lead to lower levels of motivation in individuals with severe mental illness and psychiatric professionals.
It is important for doctors and patients to know what factors help recovery from depression. Our objectives were to predict the probability of sustained recovery for patients presenting with mild to moderate depression in primary care and to devise a means of estimating this probability on an individual basis.
Participants in a randomized controlled trial were identified through general practitioners (GPs) around three academic centres in England. Participants were aged >18 years, with Hamilton Depression Rating Scale (HAMD) scores 12–19 inclusive, and at least one physical symptom on the Bradford Somatic Inventory (BSI). Baseline assessments included demographics, treatment preference, life events and difficulties and health and social care use. The outcome was sustained recovery, defined as HAMD score <8 at both 12 and 26 week follow-up. We produced a predictive model of outcome using logistic regression clustered by GP and created a probability tree to demonstrate estimated probability of recovery at the individual level.
Of 220 participants, 74% provided HAMD scores at 12 and 26 weeks. A total of 39 (24%) achieved sustained recovery, associated with being female, married/cohabiting, having a low BSI score and receiving preferred treatment. A linear predictor gives individual probabilities for sustained recovery given specific characteristics and probability trees illustrate the range of probabilities and their uncertainties for some important combinations of factors.
Sustained recovery from mild to moderate depression in primary care appears more likely for women, people who are married or cohabiting, have few somatic symptoms and receive their preferred treatment.
Therapeutic alliance between clinicians and their patients is important in community mental healthcare. It is unclear whether providing effective interventions influences therapeutic alliance.
To assess the impact of meeting previously unmet mental health needs on the therapeutic alliance between patients and clinicians.
Secondary analysis of data from a longitudinal study assessing 101 patients and paired staff.
Patient-rated unmet need was negatively associated with patient-rated and staff-rated therapeutic alliance. Staff-rated unmet need was positively associated with patient-rated therapeutic alliance only. Reducing patient-rated unmet need increased patient-rated but not staff-rated therapeutic alliance, even when controlling for other variables. Reducing staff-rated unmet need increased staff-rated but not patient-rated therapeutic alliance, but the effect became insignificant when controlling for other variables.
Patient-rated therapeutic alliance will be maximised by focusing assessment and interventions on patient-rated rather than staff-rated unmet need.
Despite considerable research investigating the relationship between a
long duration of untreated psychosis (DUP) and outcomes, there has been
much less considering predictors of a long DUP.
To investigate the clinical and social determinants of DUP in a large
sample of patients with a first episode of psychosis.
All patients with a first episode of psychosis who made contact with
psychiatric services over a 2-year period and were living in defined
catchment areas in London and Nottingham, UK were included in the ÆSOP
study Data relating to clinical and social variables and to DUP were
collected from patients, relatives and case notes.
An insidious mode of onset was associated with a substantially longer DUP
compared with an acute onset, independent of other factors. Unemployment
had a similar, if less strong, effect. Conversely family involvement in
help-seeking was independently associated with a shorter duration. There
was weak evidence that durations were longer in London than in
These findings suggest that DUP is influenced both by aspects of the
early clinical course and by the social context.