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Severity of personality disorder is an important determinant of future health. However, this key prognostic variable is not captured in routine clinical practice. Using a large clinical data-set, we explored the predictive validity of items from the Health of Nation Outcome Scales (HoNOS) as potential indicators of personality disorder severity. For 6912 patients with a personality disorder diagnosis, we examined associations between HoNOS items relating to core personality disorder symptoms (self-harm, difficulty in interpersonal relationships, performance of occupational and social roles, and agitation and aggression) and future health service use. Compared with those with no self-harm problem, the total healthcare cost was 2.74 times higher (95% CI 1.66–4.52; P < 0.001) for individuals with severe to very severe self-harm problems. Other HoNOS items did not demonstrate clear patterns of association with service costs. Self-harm may be a robust indicator of the severity of personality disorder, but further replication work is required.
National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.
To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.
Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.
A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.
SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.
Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.
To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.
Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.
Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between −8% and +6%.
Recommended enhancements to care pathways only marginally increase individual-level costs.
Health anxiety, hypochondriasis and personality disturbance commonly coexist. The impact of personality status was assessed in a secondary analysis of a randomised controlled trial (RCT).
To test the impact of personality status using ICD-11 criteria on the clinical and cost outcomes of treatment with cognitive–behavioural therapy for health anxiety (CBT-HA) and standard care over 2 years.
Personality dysfunction was assessed at baseline in 444 patients before randomisation and independent assessment of costs and outcomes made on four occasions over 2 years.
In total, 381 patients (86%) had some personality dysfunction with 184 (41%) satisfying the ICD criteria for personality disorder. Those with no personality dysfunction showed no treatment differences (P = 0.90) and worse social function with CBT-HA compared with standard care (P<0.03) whereas all other personality groups showed greater improvement with CBT-HA maintained over 2 years (P<0.001). Less benefit was shown in those with more severe personality disorder (P<0.05). Costs were less with CBT-HA except for non-significant greater differences in those with moderate or severe personality disorder.
The results contradict the hypothesis that personality disorder impairs response to CBT in health anxiety in both the short and medium term.
Reports linking the deinstitutionalisation of psychiatric care with
homelessness and imprisonment have been published widely.
To identify cohort studies that followed up or traced back long-term
psychiatric hospital residents who had been discharged as a consequence
A broad search strategy was used and 9435 titles and abstracts were
screened, 416 full articles reviewed and 171 articles from cohort studies
of deinstitutionalised patients were examined in detail.
Twenty-three studies of unique populations assessed homelessness and
imprisonment among patients discharged from long-term care. Homelessness
and imprisonment occurred sporadically; in the majority of studies no
single case of homelessness or imprisonment was reported.
Our results contradict the findings of ecological studies which indicated
a strong correlation between the decreasing number of psychiatric beds
and an increasing number of people with mental health problems who were
homeless or in prison.
Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain.
To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction.
Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources.
Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15805 v. £13410 injectable heroin and £10945 injectable methadone; P =n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin.
Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.
People with borderline personality disorder frequently experience crises.
To date, no randomised controlled trials (RCTs) of crisis interventions
for this population have been published.
To examine the feasibility of recruiting and retaining adults with
borderline personality disorder to a pilot RCT investigating the
potential efficacy and cost-effectiveness of using a joint crisis
An RCT of joint crisis plans for community-dwelling adults with
borderline personality disorder (trial registration: ISRCTN12440268). The
primary outcome measure was the occurrence of self-harming behaviour over
the 6-month period following randomisation. Secondary outcomes included
depression, anxiety, engagement and satisfaction with services, quality
of life, well-being and cost-effectiveness.
In total, 88 adults out of the 133 referred were eligible and were
randomised to receive a joint crisis plan in addition to treatment as
usual (TAU; n=46) or TAU alone (n=42).
This represented approximately 75% of our target sample size and
follow-up data were collected on 73 (83.0%) participants.
Intention-to-treat analysis revealed no significant differences in the
proportion of participants who reported self-harming (odds ratio (OR)
=1.9, 95% CI 0.53-6.5,P = 0.33) or the frequency of
self-harming behaviour (rate ratio (RR)=0.74, 95% CI 0.34-1.63,
P=0.46) between the two groups at follow-up. No
significant differences were observed between the two groups on any of
the secondary outcome measures or costs.
It is feasible to recruit and retain people with borderline personality
disorder to a trial of joint crisis plans and the intervention appears to
have high face validity with this population. However, we found no
evidence of clinical efficacy in this feasibility study.
The dangerous severe personality disorder programme was developed in high secure prisons and hospitals at great expense to identify and treat the most dangerous offenders with personality disorders.
To evaluate whether the long-term costs of the programme are greater or less than the long-term outcomes.
We used a Markov decision model with a cost-effectiveness analysis to determine the incremental cost of the programme per serious offence prevented and a cost-offset analysis to consider whether monetary benefits were greater than costs.
Costs were consistently higher for the intervention programme and the cost per serious offence prevented was over £2 million, although there was some evidence that adjustments to the programme could lead to similar interventions becoming cost-effective.
Little evidence was found to support the cost-effectiveness of the intervention programme for offenders with personality disorders, although delivery of the programme in a lower-cost prison would probably yield greater benefits than costs. There are frequent calls for mentally disordered offenders to be detained in secure hospitals rather than prisons; however, if reoffending remains the outcome of interest for policy makers, it is likely that the costs of detention in hospital will remain greater than the benefits for dangerous offenders with a personality disorder.
Aims – Nidotherapy is the systematic modification of the environment to create a better fit for people. This is the first randomized controlled trial of its efficacy in an assertive community team. Methods – Patients in an assertive outreach team with continued management problems together with comorbid personality disturbance and severe mental illness were randomized to nidotherapy enhanced assertive treatment (up to 12 sessions) or to continued assertive outreach care. Use of psychiatric beds over one years (primary outcome) and change from base-line in other health service resources, psychiatric symptoms, social functioning and engagement with services were measured at 6 and 12 months (secondary outcomes). Results – 52 patients were recruited over 13 months, with 49 and 37 assessed at 6 and 12 months. Patients referred to nidotherapy had a 63% reduction in hospital bed use after one year compared with control assertive care (P=0.13) and showed non-significant improvement in psychiatric symptoms, social functioning and engagement than the control group. The mean cost savings for each patient allocated to nidotherapy was £4,112 per year, mainly as a consequence of reduced psychiatric bed use. Conclusion – Nidotherapy may be a cost-effective option in the management of comorbid serious mental illness and personality disorder, but larger confirmatory trials are necessary.
To examine the clinical outcome and bed usage in patients with comorbid substance misuse and psychosis. The patients were randomised to ordinary assertive outreach team care or to enhanced assertive outreach with nidotherapy. Ratings of clinical symptoms, social function, engagement with services, bed usage (primary outcome after 1 year) and economic costs were assessed at baseline and at 6 and 12 months after randomisation.
Patients referred to nidotherapy had similar reduction in symptoms and engagement, with marginal superiority in social function (P = 0.045). There was a 110% reduction in hospital bed use after 1 year compared with control assertive care (P = 0.03). The mean cost savings for each patient allocated to nidotherapy was £14705 per year, mainly as a consequence of reduced psychiatric bed use.
Nidotherapy shows promise in the treatment of substance misuse and psychosis and may reduce hospital bed usage.
In making treatment decisions, psychiatrists, like other medical professionals, must adhere to rules of ethical medical conduct. They may also need to negotiate the legalities associated with detention and treatment against a patient's wishes. The growth in guidance produced by organisations such as the National Institute for Health and Clinical Excellence has added further complexity. Practitioners are increasingly required to consider cost-effectiveness in their treatment decisions and this can appear to conflict with the principles of medical ethics. With particular reference to mental healthcare, this article attempts to answer two questions: Is economic evaluation unethical? And are the methods of economic evaluation unsound for the purpose of achieving an ethical distribution of resources?
African trypanosomes have emerged as promising unicellular model organisms for the next generation of systems biology. They offer unique advantages, due to their relative simplicity, the availability of all standard genomics techniques and a long history of quantitative research. Reproducible cultivation methods exist for morphologically and physiologically distinct life-cycle stages. The genome has been sequenced, and microarrays, RNA-interference and high-accuracy metabolomics are available. Furthermore, the availability of extensive kinetic data on all glycolytic enzymes has led to the early development of a complete, experiment-based dynamic model of an important biochemical pathway. Here we describe the achievements of trypanosome systems biology so far and outline the necessary steps towards the ambitious aim of creating a ‘Silicon Trypanosome’, a comprehensive, experiment-based, multi-scale mathematical model of trypanosome physiology. We expect that, in the long run, the quantitative modelling enabled by the Silicon Trypanosome will play a key role in selecting the most suitable targets for developing new anti-parasite drugs.
Metabolomics analysis, which aims at the systematic identification and quantification of all metabolites in biological systems, is emerging as a powerful new tool to identify biomarkers of disease, report on cellular responses to environmental perturbation, and to identify the targets of drugs. Here we discuss recent developments in metabolomic analysis, from the perspective of trypanosome research, highlighting remaining challenges and the most promising areas for future research.
All of the enzymes of proline catabolism were present in Heligmosomoides polygyrus and Panagrellus redivivus and the activities were, in general, similar to those found in rat liver. Both nematodes were also shown to be able to catabolize the branched-chain amino acids leucine, isoleucine and valine, by pathways similar to those found in mammalian liver. There were no significant differences in amino acid catabolism between the animal-parasitic and free-living species of nematode.
The major transaminase in Heligmosomoides polygyrus, Panagrellus redivivus and rat liver was the 2-oxoglutarate-glutamate system, with relatively few amino acids acting as donors for the pyruvate-alanine and oxaloacetate–aspartate systems. The relative effectiveness of the different amino acid donors in the three transaminase systems was similar in all three tissues. Both H. polygyrus and P. redivivus can oxidatively deaminate a range of L-amino acids, although D-amino acid oxidase activity was low. Serine and threonine dehydratase activity and histidase activity were present in H. polygyrus and P. redivivus and both nematodes were also able to deaminate glutamine, asparagine and arginine. When NAD(H) was the cofactor the glutamate dehydrogenases of H. polygyrus and P. redivivus showed similar regulatory properties to the mammalian enzyme. However, with NADP(H) the results were anomalous. The capacity of both nematodes to transaminate and oxidatively deaminate amino acids was broadly similar and comparable to mammalian tissue. Glutamate dehydrogenase is probably the major route for deamination in these nematodes. A complete sequence of urea cycle enzymes could not be demonstrated in either P. redivivus or H. polygyrus.
Little is known about the management of health anxiety and
hypochondriasis in secondary care settings.
To determine whether cognitive–behavioural therapy (CBT) along with a
supplementary manual was effective in reducing symptoms and health
consultations in patients with high health anxiety in a genitourinary
Patients with high health anxiety were randomly assigned to brief CBT and
compared with a control group.
Greater improvement was seen in Health Anxiety Inventory (HAI) scores
(primary outcome) in patients treated with CBT (n=23)
than in the control group (n=26)
(P=0.001). Similar but less marked differences were
found for secondary outcomes of generalised anxiety, depression and
social function, and there were fewer health service consultations. The
CBT intervention resulted in improvements in outcomes alongside higher
costs, with an incremental cost of £33 per unit reduction in HAI
Cognitive–behavioural therapy for health anxiety within a genitourinary
medicine clinic is effective and suggests wider use of this intervention
in medical settings.
Major depression is an important and costly problem among adolescents, yet evidence to support the provision of cost-effective treatments is lacking.
To assess the short-term cost-effectiveness of combined selective serotonin reuptake inhibitors (SSRIs) and cognitive–behavioural therapy (CBT) together with clinical care compared with SSRIs and clinical care alone in adolescents with major depression.
Pragmatic randomised controlled trial in the UK. Outcomes and costs were assessed at baseline, 12 and 28 weeks.
The trial comprised 208 adolescents, aged 11–17 years, with major or probable major depression who had not responded to a brief initial psychosocial intervention. There were no significant differences in outcome between the groups with and without CBT. Costs were higher in the group with CBT, although not significantly so (P=0.057). Cost-effectiveness analysis and exploration of the associated uncertainty suggest there is less than a 30% probability that CBT plus SSRIs is more cost-effective than SSRIs alone.
A combination of CBT plus SSRIs is not more cost-effective in the short-term than SSRIs alone for treating adolescents with major depression in receipt of routine specialist clinical care.