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Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment.
To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use.
A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2–F6, F8–F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437).
The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242).
Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.
Declaration of interest
U.H. reports grants from the Hugo and Elsa Isler Foundation during the performance of the study.
Projected changes to post-traumatic stress disorder (PTSD) diagnostic criteria in the upcoming International Classification of Diseases (ICD)-11 may affect the prevalence and severity of identified cases. This study examined differences in rates, severity, and overlap of diagnoses using ICD-10 and ICD-11 PTSD diagnostic criteria during consecutive assessments of recent survivors of traumatic events.
The study sample comprised 3863 survivors of traumatic events, evaluated in 11 longitudinal studies of PTSD. ICD-10 and ICD-11 diagnostic rules were applied to the Clinician-Administered PTSD Scale (CAPS) to derive ICD-10 and ICD-11 diagnoses at different time intervals between trauma occurrence and 15 months.
The ICD-11 criteria identified fewer cases than the ICD-10 across assessment intervals (range −47.09% to −57.14%). Over 97% of ICD-11 PTSD cases met concurrent ICD-10 PTSD criteria. PTSD symptom severity of individuals identified by the ICD-11 criteria (CAPS total scores) was 31.38–36.49% higher than those identified by ICD-10 criteria alone. The latter, however, had CAPS scores indicative of moderate PTSD. ICD-11 was associated with similar or higher rates of comorbid mood and anxiety disorders. Individuals identified by either ICD-10 or ICD-11 shortly after traumatic events had similar longitudinal course.
This study indicates that significantly fewer individuals would be diagnosed with PTSD using the proposed ICD-11 criteria. Though ICD-11 criteria identify more severe cases, those meeting ICD-10 but not ICD-11 criteria remain in the moderate range of PTSD symptoms. Use of ICD-11 criteria will have critical implications for case identification in clinical practice, national reporting, and research.
How best to plan and provide psychosocial care following disasters remains keenly debated.
To develop evidence-informed post-disaster psychosocial management guidelines.
A three-round web-based Delphi process was conducted. One hundred and six experts rated the importance of statements generated from existing evidence using a one to nine scale. Participants reassessed their original scores in the light of others' responses in the subsequent rounds.
A total of 80 (72%) of 111 statements achieved consensus for inclusion. The statement ‘all responses should provide access to pharmacological assessment and management’ did not achieve consensus. The final guidelines recommend that every area has a multi-agency psychosocial care planning group, that responses provide general support, access to social, physical and psychological support and that specific mental health interventions are only provided if indicated by a comprehensive assessment. Trauma-focused cognitive–behavioural therapy (CBT) is recommended for acute stress disorder or acute post-traumatic stress disorder, with other treatments with an evidence base for chronic post-traumatic stress disorder being made available if trauma-focused CBT is not tolerated.
The Delphi process allowed a consensus to be achieved in an area where there are limitations to the current evidence.
Long-term data on post-traumatic stress disorder (PTSD) following
accidents are scarce.
To assess and predict PTSD in people 3 years after severe accidental
Severely injured patients were recruited consecutively from the intensive
care unit (n=121) and assessed within 1 month of the
trauma. Follow-up interviews were conducted 6 months, 12 months and 36
months later; 90 patients participated in all four interviews. Symptoms
were assessed using the Clinician-Administered PTSD Scale.
Post-traumatic stress disorder was diagnosed in 6% of patients 2 weeks
after the accident, in 2% after 1 year and in 4% after 3 years. Robust
predictors of later PTSD symptom level were intrusive symptoms shortly
after the accident and biographical risk factors. There were individual
changes over time between the categories PTSD, sub-threshold PTSD and no
PTSD. Whereas PTSD symptom severity was low or decreased for most of the
patients, some of them showed an increase or a delayed onset. Patients
with persisting PTSD symptoms at 6 months and patients with delayed onset
of symptoms are at risk of long-term PTSD.
The prevalence of PTSD was low over the whole period of 3 years.
Research on posttraumatic stress disorder (PTSD) relies mainly on self-reports of exposure to trauma and its consequences.
To analyse the consistency of the reporting of potentially traumatic events (PTEs) over time.
A community-based cohort, representative of the canton of Zurich, Switzerland, was interviewed at the ages of 34–35 years (in 1993) and 40–41 years (in 1999). A semi-structured diagnostic interview, including a section on PTSD, was administered.
Of the 342 participants who attended both interviews, 169 reported some PTE (1993, n=110; 1999, n=120). In 1999, 56 participants (33.1%) reported for the first time PTEs that actually occurred before 1993, but which had not been reported in the 1993 interview. In total, 68 participants (40.2%) who had reported a PTE in 1993 did not report it in 1999. The overall frequency of inconsistent reporting was 63.9%.
The high level of inconsistency in the reporting of PTEs has implications for therapy as well as for research.
The stability of eating disorder diagnoses has received little research attention.
To examine the course of the full range of clinical eating disorders.
A sample of 192 women with a current DSM–IV eating disorder (55 with anorexia nervosa, 108 with bulimia nervosa and 29 with eating disorder not otherwise specified) were assessed three times over 30 months using a standardised interview.
Although the overarching category of ‘eating disorder’ was relatively stable, the stability of the three specific eating disorder diagnoses was low, with just a third of participants retaining their original diagnosis. This was due only in part to remission since the remission rate was low across all three diagnoses.
There is considerable diagnostic flux within the eating disorders but a low overall remission rate. This suggests that underpinning their psychopathology may be common biological and psychological causal and maintaining processes.
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