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The history of psychiatry and homosexuality illuminates how stigma develops in the professions, how it is linked to cultural values and religious attitudes and how it affects patients. Homosexuality was medicalised as a disorder in the late 19th century and this led to treatments to change it. Same-gender contacts between men were decriminalised in many countries in the 1960s and 1970s, but – as recently as the 1980s – 30% of doctors in the USA did not think that gay students should be admitted to medical school and 40% would not allow gay doctors to specialise in paediatrics or psychiatry. Lesbians and gay men were effectively debarred from training in the main psychoanalytical schools in the USA and the UK. Although mainstream psychological treatments to make gay and bisexual people heterosexual fell into disrepute in the 1980s, so-called conversion or reparative treatments took their place and are still practised today. Transgender people have been the target of similar disapproval and attitudes towards them have been even slower to change than those towards lesbians and gay men. This stigma had consequences on the health, well-being and social inclusion of those who were lesbian, gay, bisexual and transgender (LGBT). This history suggests we need to examine where psychiatry and psychology are making similar mistakes today.
Around 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness.
A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation.
We used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics.
Overall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92–21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01–7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice.
Most people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.
Declaration of interest
H.K., S.P., M.K., S.E., P. McCrone, M.A., S.C., G.L. and G.S. report a grant from National Institute of Health Research during the conduct of the study. All other authors report having no conflicts to disclose.
Befriending by volunteers has the potential to reduce the frequent social isolation of patients with schizophrenia and thus improve health outcomes. However, trial-based evidence for its effectiveness is limited.
To conduct a randomised controlled trial of befriending for patients with schizophrenia or related disorders.
Patients were randomised to a befriending programme for 1 year or to receive information about social activities only (trial registration: ISRCTN14021839). Outcomes were assessed masked to allocation at the end of the programme; at 12 months and at a 6-month follow-up. The primary outcome was daily time spent in activities (using the Time Use Survey (TUS)) with intention-to-treat analysis.
A total of 124 patients were randomised (63 intervention, 61 active control) and 92 (74%) were followed up at 1 year. In the intervention group, 49 (78%) met a volunteer at least once and 31 (49%) had more than 12 meetings. At 1 year, mean TUS scores were more than three times higher in both groups with no significant difference between them (adjusted difference 8.9, 95% CI −40.7 to 58.5, P = 0.72). There were no significant differences in quality of life, symptoms or self-esteem. However, patients in the intervention group had significantly more social contacts than those in the control group at the end of the 12-month period. This difference held true at the follow-up 6 months later.
Although no difference was found on the primary outcome, the findings suggest that befriending may have a lasting effect on increasing social contacts. It may be used more widely to reduce the social isolation of patients with schizophrenia.
OBJECTIVES/SPECIFIC AIMS: Our primary objective was to understand the relationship between incident or recent stressful events and adherence to HIV care in the context of other person, environment, and HIV-specific stressors in a sample of Black women living with HIV (WLWH). METHODS/STUDY POPULATION: Thirty in-depth interviews were conducted with Black women living with HIV who receive care at an academic HIV primary care clinic in the Southern region of the United States to elicit stressful events influencing adherence to HIV care. Semi-structured interview guides were used to facilitate discussion regarding stressful events and adherence to HIV care. Interviews were audiotaped and transcribed verbatim. Transcripts were independently coded using a theme-based approach by two experienced coders, findings were compared, and discrepancies were resolved by discussion. RESULTS/ANTICIPATED RESULTS: Participants described frequently experiencing incident stressful events including death or serious illness of a close friend or family member, and relationship, financial, and employment difficulties. Furthermore, participants reported experiencing traumatic events such as sexual and physical abuse during childhood and adolescents. While experiencing traumatic events such as sexual and physical abuse during childhood and adolescence may be distressing, these events did not influence adherence to HIV care. However, incident stressful events as defined above did influence adherence to HIV care for some participants, but not for others. For participants who reported that stressful events did not influence adherence to HIV care, factors such as personal motivation, access to social support, and adaptive coping strategies facilitated their engagement in care. DISCUSSION/SIGNIFICANCE OF IMPACT: Experiencing stressful events, incident or traumatic, is common among Black WLWH and have the potential to negatively influence adherence to HIV care. Thus, Interventions aimed at identifying and addressing stress, social support, and coping are essential to improve adherence to HIV care behaviors.
Resting state functional magnetic resonance imaging studies have identified functional connectivity patterns associated with acute undernutrition in anorexia nervosa (AN), but few have investigated recovered patients. Thus, a trait connectivity profile characteristic of the disorder remains elusive. Using state-of-the-art graph–theoretic methods in acute AN, the authors previously found abnormal global brain network architecture, possibly driven by local network alterations. To disentangle trait from starvation effects, the present study examines network organization in recovered patients.
Graph–theoretic metrics were used to assess resting-state network properties in a large sample of female patients recovered from AN (recAN, n = 55) compared with pairwise age-matched healthy controls (HC, n = 55).
Indicative of an altered global network structure, recAN showed increased assortativity and reduced global clustering as well as small-worldness compared with HC, while no group differences at an intermediate or local network level were evident. However, using support-vector classifier on local metrics, recAN and HC could be separated with an accuracy of 70.4%.
This pattern of results suggests that long-term recovered patients have an aberrant global brain network configuration, similar to acutely underweight patients. While the finding of increased assortativity may represent a trait marker of AN, the remaining findings could be seen as a scar following prolonged undernutrition.
Catalytic growth of substantial amounts of Carbon Nanotubes (CNTs) to lengths greater than 1 – 2 cm is currently limited by several factors, including especially the deactivation of the catalyst particles due to erosion of catalyst atoms from the catalyst particles at elevated CNT growth temperatures. Inclusion of refractory metals in the CNT growth catalyst has recently been proposed as a method to prevent this catalytic particle erosion and deactivation, allowing the CNT to grow for greater times and reach substantially greater lengths. Here are presented results of recent investigations into this method. The system investigated employs Molybdenum as the erosion inhibitor and Iron as the CNT growth catalyst. Results show that inclusion of Mo leads to substantially longer catalyst particle lifetimes.
Gray matter (GM) ‘pseudoatrophy’ is well-documented in patients with anorexia nervosa (AN), but changes in white matter (WM) are less well understood. Here we investigated the dynamics of microstructural WM brain changes in AN patients during short-term weight restoration in a combined longitudinal and cross-sectional study design.
Diffusion-weighted images were acquired in young AN patients before (acAN-Tp1, n = 56) and after (acAN-Tp2, n = 44) short-term weight restoration as well as in age-matched healthy controls (HC, n = 60). Images were processed using Tract-Based-Spatial-Statistics to compare fractional anisotropy (FA) across groups and timepoints.
In the cross-sectional comparison, FA was significantly reduced in the callosal body in acAN-Tp1 compared with HC, while no differences were found between acAN-Tp2 and HC. In the longitudinal arm, FA increased with weight gain in acAN-Tp2 relative to acAN-Tp1 in large parts of the callosal body and the fornix, while it decreased in the right corticospinal tract.
Our findings reveal that dynamic, bidirectional changes in WM microstructure in young underweight patients with AN can be reversed with brief weight restoration therapy. These results parallel those previously observed in GM and suggest that alterations in WM in non-chronic AN are also state-dependent and rapidly reversible with successful intervention.
The lead article for this issue of EJAM is Prof. Bernard J. Matkowsky's personalized survey-style article on the theory and application of singular perturbation methods to noisy dynamical systems in the limit of small noise. This article is based on his John von Neumann Prize lecture presented at the Society of Industrial and Applied Mathematics (SIAM) Annual Meeting in July 2017. The John von Neumann Lecture is awarded by SIAM for outstanding and distinguished contributions to the field of applied mathematical sciences and for the effective communication of these ideas to the community. From 1990–1996, Matkowsky was an inaugural editorial board member for EJAM.
Health technology assessment (HTA) is not simply a mechanistic technical exercise as it takes place within a specific institutional context. Yet, we know little about how this context influences the operation of HTA and its ability to influence policy and practice. We seek to demonstrate the importance of considering institutional context, using a case study of Hungary, a country that has pioneered HTA in Central and Eastern Europe. We conducted 26 in-depth, semi-structured interviews with public- and private-sector stakeholders. We found that while the HTA Department, the Hungarian HTA organisation, fulfilled its formal role envisaged in the legislation, its potential for supporting evidence-based decision-making was not fully realised given the low levels of transparency and stakeholder engagement. Further, the Department’s practical influence throughout the reimbursement process was perceived as being constrained by the payer and policy-makers, as well as its own limited organisational capacity. There was also scepticism as to whether the current operational form of the HTA process delivered ‘good value for money’. Nevertheless, it still had a positive impact on the development of a broader institutional HTA infrastructure in Hungary. Our findings highlight the importance of considering institutional context in analysing the HTA function within health systems.
Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability.
To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276).
We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants.
No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = −2.14, 95% CI: −8.79, 4.51) or secondary outcomes.
Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour.
Transparency is recognised to be a key underpinning of the work of health technology assessment (HTA) agencies, yet it has only recently become a subject of systematic inquiry. We contribute to this research field by considering the Polish Agency for Health Technology Assessment (AHTAPol). We situate the AHTAPol in a broader context by comparing it with the National Institute for Health and Care Excellence (NICE) in England. To this end, we analyse all 332 assessment reports, called verification analyses, that the AHTAPol issued from 2012 to 2015, and a stratified sample of 22 Evidence Review Group reports published by NICE in the same period. Overall, by increasingly presenting its key conclusions in assessment reports, the AHTAPol has reached the transparency standards set out by NICE in transparency of HTA outputs. The AHTAPol is more transparent than NICE in certain aspects of the HTA process, such as providing rationales for redacting assessment reports and providing summaries of expert opinions. Nevertheless, it is less transparent in other areas of the HTA process, such as including information on expert conflicts of interest. Our findings have important implications for understanding HTA in Poland and more broadly. We use them to formulate recommendations for policymakers.
Taku Glacier, Alaska, USA, is currently in the advance stage of the tidewater glacier cycle. We investigated the near-terminus dynamics by measuring surface velocities, surface elevation changes, ice thickness and ablation. Velocities vary on sub-daily, diurnal, seasonal and interannual timescales. Flowline modeling shows that the modeled surface velocities are sensitive to changes in till yield strength and thus effective basal pressures. The glacier bed deepens in the up-glacier direction and this imposes a minimum subglacial water pressure necessary for water to drain along the bed. In a simple model we impose water-pressure gradients based on phreatic surfaces of constant slopes to simulate the winter–summer transitions. This proves sufficient to explain an observed early-season switch from compressional to block flow. Velocities also vary between years. Changing basal conditions can result in lower horizontal velocities, which decrease the ice supply to the terminus and result in temporary surface lowering. But a decrease in ice flux to the terminus must lead to ice storage further upstream, and that ice mass will eventually reach the terminus. This can explain the observed episodic nature of terminus advance.
The special lead article in this issue of EJAM, by Profs. John Ockendon and Brian Sleeman, is dedicated to Prof. Joseph B. Keller (referred to as Joe by his friends), Emeritus professor of Stanford University, who was one of the greatest applied mathematicians of our time. Joe died in September 2016. A workshop in honour of Joe was held at the Isaac Newton Institute for Mathematical Sciences, Cambridge, UK, in March 2017, focussing on some of the astonishingly wide range of topics in the mathematical sciences and continuum mechanics that Joe made substantial contributions to over his long career. This article discusses some of these pioneering contributions, describes some modern developments as discussed by the workshop speakers, and provides a more personal tribute to Joe, his history, and to his large influence on the international applied mathematics community. May the spirit of Joe, and his flavour of applied mathematics, continue to be reflected in EJAM.
Bipolar disorder and schizophrenia are associated with increased mortality relative to the general population. There is an international emphasis on decreasing this excess mortality.
To determine whether the mortality gap between individuals with bipolar disorder and schizophrenia and the general population has decreased.
A nationally representative cohort study using primary care electronic health records from 2000 to 2014, comparing all patients diagnosed with bipolar disorder or schizophrenia and the general population. The primary outcome was all-cause mortality.
Individuals with bipolar disorder and schizophrenia had elevated mortality (adjusted hazard ratio (HR) = 1.79, 95% CI 1.67–1.88 and 2.08, 95% CI 1.98–2.19 respectively). Adjusted HRs for bipolar disorder increased by 0.14/year (95% CI 0.10–0.19) from 2006 to 2014. The adjusted HRs for schizophrenia increased gradually from 2004 to 2010 (0.11/year, 95% CI 0.04–0.17) and rapidly after 2010 (0.34/year, 95% CI 0.18–0.49).
The mortality gap between individuals with bipolar disorder and schizophrenia, and the general population is widening.
It is not known whether increased mental health expenditure is associated with better outcomes.
To estimate the association between national mental health expenditure and (a) quality of longer-term mental healthcare, (b) service users' ratings of that care in eight European countries.
National mental health expenditure (per cent of health budget spent on mental health) was calculated from international sources. Multilevel models were developed to assess associations with quality of care and service user experiences of care using ratings of 171 facility managers and 1429 service users.
Significant positive associations were found between mental health spend and (a) six of seven quality of care domains; and (b) service user autonomy and experiences of care.
Greater national mental health expenditure was associated with higher quality of care and better service user experience.