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Specialist early intervention teams consider clinician–patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.
To describe the service use and clinical outcomes associated with the implementation of a complex intervention designed to improve care for people with depression in a primary care setting.
Health systems have limited capacity to provide appropriate psychological and pharmacological treatments for people with depression. Guidance on the treatment of depression in primary care in the United Kingdom was clarified by the National Institute for Clinical Excellence in 2004. However, there is little evidence so far of substantial changes in practice: antidepressant prescriptions continue to rise, there is limited access to psychological therapies and uncertainty persists about who should be treated for what and how. Although the welfare of staff is critical to their therapeutic engagement with patients, this is rarely an explicit focus of health systems design.
An observational study examining the implementation of a complex intervention to improve depression care called ‘Doing Well’, based in 14 general practices in a mixed urban-rural area in Scotland, United Kingdom. A small team of clinicians implemented a programme for people with low mood, depression and adjustment disorder, based on primary care. This programme incorporated a number of changes in standard mental health care, including the following: no ‘severity threshold’ for referral to secondary care; routine use of an objective measure of depression severity with continuous outcome monitoring; prompt access to guided self-help; prompt ‘step-up’ care to more formal psychological therapy or medical care, if indicated; and careful attention to staff training and satisfaction.
There was good fidelity to the model of care designed by the programme. There was a high demand for the new service (1.8% of the catchment population each year) but the programme had the capacity to manage this adequately. Clinical outcomes were satisfactory, and antidepressant use adhered to the guidelines.
Little is known of the needs of elderly patients with psychotic illnesses.
To measure the care needs of an epidemiologically based group of patients over the age of 65 years suffering from psychotic illness, using a standardised assessment.
All patients aged 65 years and over with a diagnosis of schizophrenia and related disorders from a defined catchment area were identified. Their health and social care needs were investigated using the Cardinal Needs Schedule.
The 1-year prevalence of schizophrenia and related disorders was 4.44 per 1000 of the population at risk. There were high levels of unmet need for many patients, including those in National Health Service (NHS) continuing-care beds.
Many needs were identified, all of which could be addressed using the existing skills of local health and social care professionals. The investigation raises serious concerns about standards of hospital and community care for elderly patients with schizophrenia. The findings may be unique, reflecting long-standing problems within a particularly hard-pressed part of the NHS. However, it is not known whether a similar situation exists in other parts of the UK.
The concept of early intervention for psychosis has received much attention in recent years. The experience of pioneer services in the USA and Australia has convinced the UK Government to set aside millions of pounds to make dedicated early intervention teams an integral part of standard mental health services across the country. Other governments are set to follow suit. The rationale for early intervention is that there is a higher success rate if psychotic symptoms are treated early than if they are treated after they have been present for some time. It is also claimed that interventions early in the course of the illness can decrease the psychosocial impact of a psychotic illness that leads to secondary disability. But have these assertions been empirically demonstrated? Do such services simply take valuable resources, both in terms of funding and staff, from an already-overstretched mental health system, or do they change the trajectory of the disease process in a fundamental way? Dr Max Birchwood, Director of the Birmingham Early Intervention Service, and Dr Anthony Pelosi, consultant psychiatrist with a ‘generic’ community service in East Kilbride, Scotland, debate this issue.
From 686 patients attending primary care physicians, 77 were identified by a screening procedure as having chronic fatigue. Of these, 65 were given a comprehensive psychological, social and physical evaluation. Seventeen cases (26%) met criteria for the chronic fatigue syndrome. Forty-seven (72%) received an ICD-9 diagnosis of whom 23 had neurotic depression, with a further 5 meeting criteria for neurasthenia. Forty-nine were ‘cases’ as defined by the revised Clinical Interview Schedule (CIS-R), and 42 if the fatigue item was excluded. Psychiatric morbidity was more related to levels of social stresses than was severity of fatigue. The main difference between these subjects and those examined in hospital settings is that the former are less liable to attribute their symptoms to wholly physical causes, including viruses, as opposed to social or psychological factors. Identification and management of persistent fatigue in primary care may prevent the secondary disabilities seen in patients with chronic fatigue syndromes.
Many of the standardized interviews currently used in psychiatry require the interviewer to use expert psychiatric judgements in deciding upon the presence or absence of psychopathology. However, when case definitions are standardized it is customary for clinical judgements to be replaced with rules. The Clinical Interview Schedule was therefore revised, in order to increase standardization, and to make it suitable for use by ‘lay’ interviewers in assessing minor psychiatric disorder in community, general hospital, occupational and primary care research.
Two reliability studies of the revised Clinical Interview Schedule (CIS-R) were conducted in primary health care clinics in London and Santiago, Chile. Both studies compared psychiatrically trained interviewer(s) with lay interviewer(s). Estimates of the reliability of the CIS-R compared favourably with the results of studies of other standardized interviews. In addition, the lay interviewers were as reliable as the psychiatrists and did not show any bias in their use of the CIS-R. Confirmatory factor analysis models were also used to estimate the reliabilities of the CIS-R and self-administered questionnaires and indicated that traditional measures of reliability are probably overestimates.
Case-control studies involve ‘cases' being compared to ‘controls' with respect to ‘exposures', possible aetiological (or associated) factors. Associations between a disease and an exposure can be explained by chance, reverse causality, confounding and biases or, lastly, by causality. However, confounders as well as information and selection biases can be adjusted for at the design (or analysis) stage of the study. The strength of an association can be measured by means of relative risk, calculated indirectly using the odds ratio. Well conducted control studies should produce accurate estimates of relative risks in many psychiatric investigations.
The Somali Counselling Project was established in London's East End in December 1986 with the support of a grant from the City Parochial Foundation. It offers social support and psychosocial counselling to Somalis and other culturally related peoples from the Horn of Africa who are living in the United Kingdom. Its aims are: to advise on social, administrative and financial problems; to help clients make effective use of mainstream health services; to prevent and treat emotional disorder; and to provide administrative and emotional assistance to those with uncertain immigration status.
This paper describes the development, validation and use of a computerized assessment for minor psychiatric disorder based on the Clinical Interview Schedule (CIS; Goldberg et al. 1970). There was good agreement between the computerized assessment and the CIS administered by psychiatrists, both in assessing overall severity and in defining ‘cases’ of psychiatric disorder. Individual symptoms elicited by the computer and the CIS were compared, and the levels of agreement found were similar to those from inter-observer studies of standardized interviews. Subjects from a variety of non-psychiatric settings regarded the assessment as acceptable, accurate and easy to use. It is concluded that this computerized assessment of neurotic symptoms is valid and reliable. It eliminates observer bias, it is an efficient use of research resources and it may have clinical applications in primary care.