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During the last 20 years there has been increased focus on the problem of premature mortality among people with schizophrenia. This has resulted in a focus on weight gain, the development of metabolic problems, the need to understand the mechanisms behind these and the need to identify strategies to manage these problems. Audit programmes have highlighted the poor quality of monitoring for, and management of, physical health problems in people with all types of mental health disorder but particularly for those with psychotic illnesses. Further, weight gain also reinforces service users’ negative views of themselves and may lead to poor adherence with treatment (Faulkner et al., 2007; Lester et al., 2011; Weiden et al., 2004).
Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive.
To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis.
Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening.
Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37–20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33–10.10).
The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.
We conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive.
Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive–behavioural therapy.
CTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.
Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact.
To examine associations between changes in staff, and patient satisfaction and quality of care.
A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder.
Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments.
Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients.
In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population.
To examine the quality of assessment and treatment of physical health problems in people with schizophrenia.
Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey.
Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received.
Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.
Decades of research on social skills assessment and intervention indicates the importance of social skills in improving academic achievement. Additionally, a strong evidence base promotes the inclusion of social–emotional learning into the whole school curriculum. In recognition of this evidence, the new Australian Curriculum, under Personal and social capability, calls for students to develop social skills. For many students with additional needs, it is hoped that the development of social skills will enable increased connectedness and a greater sense of inclusion. To meet developmental expectations of social skills, teachers need to measure these skills, develop effective teaching strategies for them, and evaluate their progress. The multi-tiered assessment and intervention components of the Social Skills Improvement System (SSiS; Elliott & Gresham, 2007) seem to offer a comprehensive system to support this process (Elliott, Frey, & Davies, in press).
End tidal CO2 (ETCO2) has been established as a standard for confirmation of an airway, but its role is expanding. In certain settings ETCO2 closely approximates the partial pressure of arterial CO2 (PaCO2) and has been described as a tool to optimize a patient's ventilatory status. ETCO2 monitors are increasingly being used by EMS personnel to guide ventilation in the prehospital setting. Severely traumatized and burn patients represent a unique population to which this practice has not been validated.
The sole use of ETCO2 to monitor ventilation may lead to avoidable respiratory acidosis.
A consecutive series of patients with burns or trauma intubated in the prehospital setting over a 24-month period were evaluated. Prehospital arrests were excluded. Absence of ETCO2 transport data and patients without an arterial blood gas (ABG) within 15 minutes of arrival were also excluded. Data collected included demographics, place and time of intubation, service performing intubation, ETCO2 maintained en-route to hospital, and ABG upon arrival. Further data included length of stay, mortality, and injury severity scores.
One hundred sixty patients met the inclusion criteria. Prehospital ETCO2 did not correlate with measured PaCO2 (R2 = 0.08). Mean ETCO2 was significantly lower than mean PaCO2 (34 mmHg vs 44 mmHg, P < .005). Patients arriving acidotic were more likely to die. Mean pH on arrival for survivors and decedents was 7.32 and 7.19 respectively (P < .001). Mortality, acidosis, higher base deficits, and more severe injury patterns were all predictors for a worse correlation between ETCO2 and PaCO2 and increased mean difference between the two values. Decedents and patients presenting with a pH <7.2 demonstrated the greatest discrepancy between ETCO2 and PaCO2. The data suggest that patients may be hypoventilated by prehospital providers in order to obtain a prescribed ETCO2.
ETCO2 is an inadequate tool for predicting PaCO2 or optimizing ventilation in severely injured patients. Adherence to current ETCO2 guidelines in the prehospital setting may contribute to acidosis and increased mortality. Consideration should be given to developing alternate protocols to guide ventilation of the severely injured in the prehospital setting.
CooperCJ, KraatzJJ, KubiakDS, KesselJW, BarnesSL. Utility of Prehospital Quantitative End Tidal CO2?. Prehosp Disaster Med. 2013;28(2):1-6.
Genetic factors contribute to the individual variability in weight gain caused by several antipsychotic drugs. The FTO gene is associated with obesity in the general population; we have investigated whether a common risk polymorphism (rs9939609) in this gene is associated with antipsychotic drug-induced weight gain and obesity. Two samples were studied: (1) 93 first-episode patients receiving antipsychotic drugs for the first time and having body weight monitored for up to 12 months; (2) 187 chronic patients with schizophrenia assessed for measures of obesity and metabolic dysfunction. No association of FTO genotype with weight gain was found in initially drug-naive patients. The chronically treated patients had a significant association of genotype with body mass index (BMI), reflected in associations with waist circumference, waist:hip ratio and the frequency of central obesity. These findings indicate that FTO genotype has a major effect on body weight determined by BMI in chronically treated patients with schizophrenia.
Substance misuse is a common comorbid problem in people presenting with
first-episode psychosis and is associated with a poor short-term
The aim of this study is to examine differences in baseline
characteristics and 1-year outcome between individuals with first-episode
psychosis who have never misused substances, those who stop misusing
substances after initial presentation and those who persistently misuse
substances over the 1-year assessment period.
Patients were recruited to the Northern Ireland First Episode Psychosis
Study (n = 272). Clinical assessments were performed at baseline and at 1
year (n = 194) and data were collected from the case notes.
Individuals with persistent substance misuse had more severe depression,
more positive symptoms, poorer functional outcome and greater rates of
relapse at 1 year than those who stopped and those who had never misused
substances. There were no differences in outcome between people who had
never misused substances and those who stopped misusing after
These results support assertive intervention targeted at comorbid
substance misuse in individuals with first-episode psychosis.
Researching psychotic disorders in unison rather than as separate
diagnostic groups is widely advocated, but the viability of such an
approach requires careful consideration from a neurocognitive
To describe cognition in people with bipolar disorder and schizophrenia
and to examine how known causes of variability in individual's
performance contribute to any observed diagnostic differences.
Neurocognitive functioning in people with bipolar disorder
(n = 32), schizophrenia (n = 46) and
healthy controls (n = 67) was compared using analysis of
covariance on data from the Northern Ireland First Episode Psychosis
The bipolar disorder and schizophrenia groups were most impaired on tests
of memory, executive functioning and language. The bipolar group
performed significantly better on tests of response inhibition, verbal
fluency and callosal functioning. Between-group differences could be
explained by the greater proclivity of individuals with schizophrenia to
experience global cognitive impairment and negative symptoms.
Particular impairments are common to people with psychosis and may prove
useful as endophenotypic markers. Considering the degree of individuals'
global cognitive impairment is critical when attempting to understand
patterns of selective impairment both within and between these diagnostic
Obesity and metabolic syndrome are significant problems for patients
taking antipsychotic drugs. Evidence is emerging of genetic risk
To investigate the influence of two candidate genes, smoking and drug
treatment on obesity and metabolic syndrome in patients with
Patients (n=134) were assessed for measures of obesity, other factors
contributing to metabolic syndrome, and two genetic polymorphisms
(5-HT2C receptor −759C/T and leptin −2548A/G).
Neither genotype nor smoking was significantly associated with measures
of obesity. However, both leptin genotype and smoking were significantly
associated with metabolic syndrome. Significant interaction occurred
between the genetic polymorphisms for effects on obesity, whereby a
genotype combination increased risk. Drug treatment showed significant
effects on measures of obesity and triglyceride concentrations;
risperidone was associated with lower values than olanzapine or
The findings suggest interacting genetic risk factors and smoking
influence development of metabolic syndrome in patients on antipsychotic
This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.
The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.
One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.
The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.