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Mental health problems early in life can negatively impact educational attainment, which in turn have negative long-term effects on health, social and economic opportunities. Our aims were to: (i) estimate the impacts of different types of psychiatric conditions on educational outcomes and (ii) to estimate the proportion of adverse educational outcomes which can be attributed to psychiatric conditions.
Participants (N = 2511) were from a school-based community cohort of Brazilian children and adolescents aged 6–14 years enriched for high family risk of psychiatric conditions. We examined the impact of fear- (panic, separation and social anxiety disorder, specific phobia, agoraphobia and anxiety conditions not otherwise specified), distress- (generalised anxiety disorder, major depressive disorder and depressive disorder not otherwise specified, bipolar, obsessive-compulsive, tic, eating and post-traumatic stress disorder) and externalising-related conditions (attention deficit and hyperactivity disorder, conduct and oppositional-defiant conditions) on grade repetition, dropout, age-grade distortion, literacy performance and bullying perpetration, 3 years later. Psychiatric conditions were ascertained by psychiatrists, using the Development and Well-Being Behaviour Assessment. Propensity score and inverse probability weighting were used to adjust for potential confounders, including comorbidity, and sample attrition. We calculated the population attributable risk percentages to estimate the proportion of adverse educational outcomes in the population which could be attributed to psychiatric conditions. Analyses were conducted separately for males and females.
Fear and distress conditions in males were associated with school dropout (odds ratio (OR) = 2.76; 95% confidence interval (CI) = 1.06, 7.22; p < 0.05) and grade repetition (OR = 2.76; 95% CI = 1.32, 5.78; p < 0.01), respectively. Externalising conditions were associated with grade repetition in males (OR = 1.66; 95% CI = 1.05, 2.64; p < 0.05) and females (OR = 2.03; 95% CI = 1.15, 3.58; p < 0.05), as well as age-grade distortion in males (OR = 1.66; 95% CI = 1.05, 2.62; p < 0.05) and females (OR = 2.88; 95% CI = 1.61, 5.14; p < 0.001). Externalising conditions were also associated with lower literacy levels (β = −0.23; 95% CI = −0.34, −0.12; p < 0.001) and bullying perpetration (OR = 3.12; 95% CI = 1.50, 6.51; p < 0.001) in females. If all externalising conditions were prevented or treated, we estimate that 5.0 and 4.8% of grade repetition would not have occurred in females and males, respectively, as well as 10.2 (females) and 5.3% (males) of age-grade distortion cases and 11.4% of female bullying perpetration.
The study provides evidence of the negative impact of psychiatric conditions on educational outcomes in a large Brazilian cohort. Externalising conditions had the broadest and most robust negative impacts on education and these were particularly harmful to females which are likely to limit future socio-economic opportunities.
The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective.
To assess the clinical effectiveness over 6 years and the impact on costs and care home admission.
We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission.
In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35).
START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers.
Declarations of interest
G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
Reconciliation of unpaid care and employment is an increasingly important societal, economic and policy issue, both in the UK and internationally. Previous research shows the effectiveness of formal social care services in enabling carers to remain in employment. Using quantitative and qualitative data collected from carers and the person they care for in 2013 and 2015, during a period of cuts to adult social care in England, we explore barriers experienced to receipt of social care services. The main barriers to receipt of services identified in our study were availability, characteristics of services such as quality, and attitudes of carer and care-recipient to receiving services. These barriers have particular implications for carers' ability to reconcile care and employment.
This paper explores the effectiveness of paid services in supporting unpaid carers’ employment in England. There is currently a new emphasis in England on ‘replacement care’, or paid services for the cared-for person, as a means of supporting working carers. The international evidence on the effectiveness of paid services as a means of supporting carers’ employment is inconclusive and does not relate specifically to England. The study reported here explores this issue using the 2009/10 Personal Social Services Survey of Adult Carers in England. The study finds a positive association between carers’ employment and receipt of paid services by the cared-for person, controlling for covariates. It therefore gives support to the hypothesis that services for the cared-for person are effective in supporting carers’ employment. Use of home care and a personal assistant are associated on their own with the employment of both men and women carers, while use of day care and meals-on-wheels are associated specifically with women's employment. Use of short-term breaks are associated with carers’ employment when combined with other services. The paper supports the emphasis in English social policy on paid services as a means of supporting working carers, but questions the use of the term ‘replacement care’ and the emphasis on ‘the market’.
Many long-term care systems in economically developed countries are reliant on informal care. However, in the context of population ageing, there are concerns about the future supply of informal care. This article reports on projections of informal care receipt by older people with disabilities from spouses and (adult) children to 2032 in England. The projections show that the proportions of older people with disabilities who have a child will fall by 2032 and that the extent of informal care in future may be lower than previously estimated. The policy implications, in the context of the Dilnot Commission's report, are explored.
In England, Local Authorities (LAs) contribute to the care home fees of two-thirds of care home residents aged 65+ who pass a means test. LAs typically pay fees below those faced by residents excluded from state support. Most proposals for reform of the means test would increase the proportion of residents entitled to state support. If care homes receive the LA fee for more residents, they might increase fees for any remaining self-funders. Alternatively, the LA fee might have to rise. We use two linked simulation models to examine how alternative assumptions on post-reform fees affect projected public costs and financial gains to residents of three potential reforms to the means test. Raising the LA fee rate to maintain income per resident would increase the projected public cost of the reforms by between 22% and 72% in the base year. It would reduce the average gain to care home residents by between 8% and 12%. Raising post-reform fees for remaining self-funders or requiring pre-reform self-funders to meet the difference between the LA and self-funder fees, reduces the gains to residents by 28–37%. For one reform, residents in the highest income quintile would face losses if the self-funder fee rises.
Using two linked simulation models, we examine the public expenditure costs and distributional effects of potential reforms to long-term care funding in the UK. Changes to the means tests for user contributions to care costs are compared with options for the abolition of these means tests (‘free’ personal care). The latter generally cost more than the former and benefit higher income groups more than those on lower incomes (measuring income in relation to the age-specific income distribution). Reforms to the means tests target benefits towards those on lower incomes. However, the highest income group are net losers if free personal care is financed by a higher tax rate on higher incomes and the effect on the whole population considered.
The future market costs of long-term care for older people will be affected by the extent of informal care. This paper reports on projections of receipt of informal care by disabled older people from their spouses and (adult) children to 2031 in England. The paper shows that, over the next 30 years, care by spouses is likely to increase substantially. However, if current patterns of care remain the same, care by children will also need to increase by nearly 60 per cent by 2031. It is not clear that the supply of care by children will rise to meet this demand.
Several factors are thought to influence resource use and costs in treating schizophrenia.
To assess the relative impact of non-adherence and other factors associated with resource use and costs incurred by people with schizophrenia.
Secondary analyses were made of data from a 1994 national survey of psychiatric morbidity among adults living in institutions in the UK. Factors potentially relating to resource use and costs were examined using two-part models.
Patients who failed to adhere to their medication regimen were over one-and-a-halftimes as likely as patients who did adhere to it to report use of in-patient services. Non-adherence is one of the most significant factors in increasing external service costs, by a factor of almost 3. Non-adherence predicted an excess annual cost per patient of approximately $2500 for in-patient services and over $5000 for total service use.
Resource use and costs are influenced by various factors. Medication non-adherence consistently exhibits an association with higher costs. Further important factors are patient needs and the ability of the system to address them.
The inverse barometer effect (IBE) is the isostatic response of ocean surface height to changes in atmospheric pressure (Pair) at a rate of about 1 cm hPa−1. The IBE is a significant contributor to variability of ice-shelf surface elevation (ηice), as we demonstrate with simultaneous global positioning system measurements of ηice and local measurements of Pair from the Amery, Brunt and Ross Ice Shelves, Antarctica. We find that an IBE correction is justified for frequencies (ω) covering the “weather band”, 0.03 < ω < 0.5 cpd (cycles per day). The IBE correction reduces the standard deviation of the weather-band signal of ηice from ∼9 cm to ∼3 cm. With this correction, the largest remaining high-frequency error signal in ηice is the inaccuracy of the present generation of Antarctic tide models, estimated to be of order 10 cm for most of Antarctica.
The subject of this book is astrophysical accretion, especially in those circumstances where accretion is believed to make an important contribution to the total light of an astrophysical system. Our discussion therefore centres mainly on close binary systems containing compact objects and on active nuclei. The reader is assumed to possess a basic knowledge of physics at first degree level, but only a rudimentary experience of astronomy is required. We have tried to concentrate on those features, particularly the basic physics, that are probably more firmly established; but the treatment is necessarily somewhat heterogeneous. For example, there is by now a tolerably coherent line of argument showing that the formation of an accretion disc is very likely in many close binaries, and giving a plausible picture of what such a disc is like, at least in some simple cases. In other areas, such as accretion on to the surface of a compact object, or in active nuclei, we are not so fortunate, and we must work back and forth between theory and observation. Our aim is that the book should provide a systematic introduction to the subject for graduate students. We hope it may also serve as a reference for interested astronomers in other fields, and that selected material will be suitable for undergraduate options in astronomy.
In Chapters 2 and 3 we present introductory material on fluid dynamics and plasma physics. Many excellent texts exist in these areas, but they tend to be too detailed for our needs; we have tried to extract just those basic ideas necessary for the subsequent discussion, and to set them in an astrophysical context.
Whenever we need to consider the behaviour of a gas on lengthscales comparable to the mean free path between collisions, we must use the ideas of plasma physics. In this chapter we shall briefly introduce some of the concepts that will be important to our study of accretion.
A plasma differs from an atomic or molecular gas in that it consists of a mixture of two gases of electrically charged particles: an electron gas and an ion gas, with very different particle masses me and mi.
The electrons and ions interact with each other through their electrostatic Coulomb attractions and repulsions. These Coulomb forces decrease only slowly (∞ r-2) with distance and do not have a characteristic lengthscale. Thus, a plasma particle interacts with many others at any one instant, and this makes the description of collisions more complicated than in atomic or molecular gases, where the interparticle forces are very short-range. A further complication arises from the great difference in particle masses me and mi. Since collisions between particles of very different masses can transfer only a small fraction of the kinetic energy of order me/mi ≪ 1, it is possible for electrons and ions to have significantly different temperatures over appreciable timescales. These two properties – the long-range nature of the Coulomb force and the disparity in electron and ion masses – give the physics of plasmas its particular character. A further series of complex phenomena occurs when the plasma is permeated by a large-scale magnetic field; this is particularly relevant for the study of gas accreting on to highly magnetized neutron stars and white dwarfs.
We have seen in the foregoing chapters that a huge variety of accretion flows are at least theoretically possible. The equations describing axially symmetric flows with gravity, pressure and rotation allow a wide array of solutions of astrophysical interest. If one includes Ω = 0 (no rotation) as a special case, then even ordinary stars and spherically symmetrical Bondi accretion are solutions. More realistically, accretion flows with low angular momentum may produce supersonic flows which shock at smaller radii if they lack pressure support, or produce settling, cooling solutions if partially supported by pressure. We have already studied in detail spherically symmetrical accretion, the standard thin disc, and thick discs, and we will study other solutions which have acquired recognition in the astrophysical literature, such as slim discs and advection dominated accretion flows (ADAFs). In this chapter we shall attempt to organize all the different solutions into a coherent picture in order to clarify their relation to each other.
The fact that black holes possess an event horizon instead of a hard surface makes the inner boundary condition for black hole accretion flows qualitatively different from that for a normal star, and allows the existence of a family of solutions in which a significant fraction of the dissipated energy is advected through the horizon. Hence, for an external distant observer, ADAFs on to black holes are characterized by a low radiative efficiency η. (In ADAFs on to objects with a hard surface the advected energy must be ultimately reprocessed and released near the surface – see Section 11.8.3.)