Reliable self-report of health service use by individuals with serious mental illness

Patterns of Self-Reported Mental Health Symptoms and Treatment among People Booked into a Large Metropolitan County Jail

The Brief Jail Mental Health Screen (BJMHS) is one of the most well-known and frequently used tools to conduct routine mental health screening at jail intake. In prior research, the BJMHS results typically have been evaluated overall (i.e., yes/no positive screen). However, there is heterogeneity in symptom presentation and treatment histories among people with serious mental illness, and there are potential consequences of this heterogeneity for mental health administration and policy in jails. We conducted a latent class analysis of BJMHS item-level results using administrative data for 37,998 people booked into a southeastern, metropolitan, U.S. county jail over a 3.5-year period. A 4-class solution provided the best fitting and most interpretable model. The largest class (89.5%) comprised people unlikely to report symptoms or treatment histories (limited symptoms). The next class comprised people who were unlikely to report ongoing symptoms but reported medication and hospitalization (managed symptoms). The third class (2.5%) included people likely to report feeling useless/sinful, prior hospitalization, and current psychiatric medication (depressive symptoms). The fourth class (1.0%) comprised people likely to report thought control, paranoia, feeling useless/sinful, medication, and hospitalization (psychotic symptoms). Controlling for sociodemographic and booking characteristics, people in the managed, depressive, and psychotic symptoms classes had significantly longer jail stays compared to those in the limited symptoms class. People in the managed and depressive symptoms classes were at heightened risk of re-arrest compared to the limited symptoms class. Findings can inform case prioritization and the allocation of resources to support efficient and effective jail-based mental health services.

Cost of post-deployment screening for mental illness in the UK military: findings from a cluster randomised controlled trial

BACKGROUND

Little is known about the economic impact of military mental health screening.

AIMS

To investigate (a) whether post-deployment screening of military personnel affects use and cost of services and (b) the impact of psychiatric morbidity on costs.

METHODS

Participants were recruited from UK Royal Marine and Army platoons and randomised to an intervention group (which received tailored advice predicated upon mental health status) or a control group (which received general advice following assessment of mental health status). The intervention costs were calculated while service use and associated costs were assessed at 12-month follow-up.

RESULTS

Data were available for 6323 participants. Mean screening cost was £34. Service costs were slightly higher in the control group compared to the intervention group (£1197 vs. £1147) which was not statistically significant (bootstrapped 95%CI, -£363 to £434. In both groups, screening and control, costs were significantly higher for those who screened positive for mental health problems.

CONCLUSIONS

Costs were not affected by screening. In countries that have already implemented post-deployment screening, the political cost of disinvestment needs careful consideration. Those who develop psychiatric morbidity have substantially higher care costs than those who do not.

A Year Into the Pandemic: The Diversity of Experience Amongst People With Severe Mental Ill Health

BACKGROUND

The COVID-19 pandemic has amplified pre-existing health inequalities and people with severe mental ill health (SMI) are one of the groups at greatest risk. In this study, we explored the effects of the pandemic and pandemic restrictions on people with SMI during the first year of the pandemic.

METHODS

We conducted a longitudinal study in a sample of people with SMI. The inception survey was carried out between July and December 2020. Participants were then re-surveyed between January and March 2021. People were contacted by telephone and invited to take part in the study over the phone, online or by postal questionnaire. Across both waves we asked participants about their physical and mental health, health risk behaviors, well-being, loneliness, and employment status.

RESULTS

Three hundred and sixty-seven people with SMI completed the inception survey and 249 people completed the follow up. Whilst some people reported no change in their physical (77, 31%) or mental health (60, 24%) over the course of the pandemic 53 (21%) reported a continuing decline in physical health and 52 (21%) reported a continuing decline in mental health. Participants who maintained a daily routine or reported no decline in physical health were found to be associated with no deterioration in mental health (Daily routine OR 2.27, 95% CI 1.11-4.64; no reported physical health decline OR 0.54, 95% CI 0.17-0.70). Participants were less likely to be occupationally active in the first phase of the pandemic compared to before the pandemic and in the second phase of the pandemic. However, there was no one single experience of people with SMI and similar to studies in the general populations a range of different scenarios was experienced.

CONCLUSIONS

We observed a series of factors that might amplify pre-existing health inequalities. Health systems should be mindful of this, and should redouble efforts to set in place changes to practice and policy, which can mitigate these inequalities. Examples might include; raising awareness of the importance of ensuring that people with SMI receive an annual physical health check and supporting people to maintain a daily routine.

Influences on emergency department attendance among frail older people with deteriorating health: a multicentre prospective cohort study

OBJECTIVES

To examine the patterns and influences on repeated emergency department attendance among frail older people with deteriorating health.

STUDY DESIGN

Multicentre prospective cohort study (International Access Rights and Empowerment II study) with convergent mixed methods design.

METHODS

Eligible patients were aged ≥65 years, with Clinical Frailty Score ≥5, and ≥1 hospital admission or ≥2 acute attendances in the previous 6 months. Questionnaires were administered to participants over 6 months and we extracted clinical data from the medical records. We conducted modified Poisson multivariable regression analysis to identify factors associated with repeated emergency department attendance (≥2 over 6 months) and thematic analysis of qualitative interviews.

RESULTS

A total of 90 participants were recruited. The mean age was 84 years, and 63% were women. Of 87 participants, 21 experienced repeated emergency department attendance. Severe and/or overwhelming pain (adjusted prevalence ratio 2.44, 95% confidence interval 1.17-5.11), greater number of comorbidities (1.32, 1.08-1.62), ≥10 community nursing contacts (2.93, 1.31-6.56), and a total of ≥2 weeks spent in hospital during the previous 6 months (2.91, 1.24-6.84) were associated with repeated attendance. From 45 interviews, we identified influences on emergency department attendance: 1. inaccessibility of community healthcare; 2. perceived barriers to community healthcare seeking; 3. perceived benefits of hospital admission; 4. barriers to recovery during previous hospital admission (unsuitable food, inactivity); and 5. poorly coordinated transitions between settings.

CONCLUSIONS

We identified missed opportunities to optimise older people's recovery during hospital admission, such as improved food and a timely and coordinated discharge, which may reduce reattendances. Proactive care in the community with systematic assessment of symptoms may be required, particularly for those with multimorbidity.

Perceptions and experiences of living with coexisting type 2 diabetes and severe mental illness: a scoping review

AIMS

To map existing research-based knowledge of everyday life and illness management among people with coexisting type 2 diabetes and severe mental illness, and to identify study designs, aims, populations and themes.

METHODS

A systematic literature search was performed on 16 April 2019 using Medline, Embase, PsycINFO, Cinahl, the Cochrane Library, and the Web of Science to conduct a scoping review. Included studies were summarized with regard to the quantity of research, the study designs, aims, populations and themes RESULTS: From 3406 records, we included 23 studies about everyday life and illness management among people with coexisting type 2 diabetes and severe mental illness. Four studies were qualitative (observations, interviews and focus groups), and 19 were quantitative (observational and interventions) and used questionnaires. Five themes emerged in the findings: (1) diet and exercise, but not other diabetes self-care activities, are consistently compromised in the target group; (2) psychiatric exacerbation diminishes diabetes self-care; (3) social support and high self-efficacy improve diabetes self-care; (4) use of healthcare services is compromised; and (5) quality of life and well-being is poor.

CONCLUSIONS

The limited research into the studied population's experiences with coexisting type 2 diabetes and severe mental illness is characterized by its heterogeneity in aims and methods and a strong focus on diabetes management and treatment. Further research focusing on the management of both conditions in everyday life is needed to improve specialized and integrated care targeting the population.

Recent physical conditions and health service utilization in people with common mental disorders and severe mental illness in England: Comparative cross-sectional data from a nationally representative sample

Background.

Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders.

Methods.

We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups.

Results.

Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42–1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50–9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population.

Conclusions.

People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.

An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial

BACKGROUND

Depression is a common antenatal mental disorder associated with significant maternal morbidity and adverse fetal outcomes. However, there is a lack of research on the effectiveness or cost-effectiveness of psychological interventions for antenatal depression.

METHODS

A parallel-group, exploratory randomised controlled trial across five hospitals. The trial compared Guided Self-Help, modified for pregnancy, plus usual care with usual care alone for pregnant women meeting DSM-IV criteria for mild-moderate depression. The trial objectives were to establish recruitment/follow-up rates, compliance and acceptability, and to provide preliminary evidence of intervention efficacy and cost-effectiveness. The primary outcome of depressive symptoms was assessed by blinded researchers using the Edinburgh Postnatal Depression Scale at 14-weeks post-randomisation.

RESULTS

620 women were screened, 114 women were eligible and 53 (46.5%) were randomised. 26 women received Guided Self-Help - 18 (69%) attending ≥4 sessions - and 27 usual care; n = 3 women were lost to follow-up (follow-up rate for primary outcome 92%). Women receiving Guided Self-Help reported fewer depressive symptoms at follow-up than women receiving usual care (adjusted effect size -0.64 (95%CI: -1.30, 0.06) p = 0.07). There were no trial-related adverse events. The cost-effectiveness acceptability curve showed the probability of Guided Self-Help being cost-effective compared with usual care ranged from 10 to 50% with a willingness-to-pay range from £0 to £50,000.

CONCLUSIONS AND LIMITATIONS

Despite intense efforts we did not meet our anticipated recruitment target. However, high levels of acceptability, a lack of adverse events and a trend towards improvements in symptoms of depression post-treatment indicates this intervention is suitable for talking therapy services.

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT

BACKGROUND

Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor.

OBJECTIVES

The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested.

DESIGN

This was a three-arm, single-blind, parallel randomised controlled trial.

SETTING

A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited.

PARTICIPANTS

A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised.

INTERVENTIONS

The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC.

RANDOMISATION

Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation.

MAIN OUTCOME MEASURES

The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score.

RESULTS

The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective.

CONCLUSIONS

Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN84864870.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.

"It's Not Like Therapy": Patient-Inmate Perspectives on Jail Psychiatric Services

Jails may serve an important public health function by treating individuals with psychiatric problems. However, scholars debate the service qualities that can best achieve this aim. Some suggest the possibility of comprehensive psychiatric services in jails, while others recommend a narrower focus on basic elements of care (assessments, medication management, and crisis intervention). To date, this debate remains uninformed by service recipients. This qualitative study addresses this gap by illuminating patient-inmate perspectives on jail psychiatric services. Patient-inmate experiences indicate that the jail environment is incongruent with the provision of comprehensive psychiatric services. Thus, program administrators would best serve patient-inmates by strengthening basic services and connections to community-based providers who can provide comprehensive and effective care.

Patient involvement in improving the evidence base on mental health inpatient care: the PERCEIVE programme

Background

Despite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programme provides a particular focus on the inclusion of the patient’s perspective in the development and evaluation of evidence.

Objectives

To understand how changes to inpatient care affect the perceptions of the ward by service users and staff by using stakeholder participatory methods.

Design

The programme consisted of four work packages (WPs). (1) Lasting Improvements for Acute Inpatient SEttings (LIAISE): using participatory methods we developed two new scales [Views On Therapeutic Environment (VOTE) for staff and Views On Inpatient CarE (VOICE) for service users]. (2) Client Services Receipt Inventory – Inpatient (CITRINE): working with nurses and service users we developed a health economic measure of the amount of contact service users have with staff. The self-report measure records interactions with staff as well as the number of therapeutic activities attended. (3) Delivering Opportunities for Recovery (DOORWAYS): a stepped-wedge randomised controlled trial to test if training ward nurses to deliver therapeutic group activities would improve the perception of the ward by service users and staff. A total of 16 wards were progressively randomised and we compared the VOICE, VOTE and CITRINE measures before and after the intervention. A total of 1108 service users and 539 staff participated in this trial. (4) Bringing Emergency TreatmenT to Early Resolution (BETTER PATHWAYS) was an observational study comparing two service systems. The first was a ‘triage’ system in which service users were admitted to the triage ward and then either transferred to their locality wards or discharged back into the community within 7 days. The second system was routine care. We collected data from 454 service users and 284 nurses on their perceptions of the wards.

Main outcome measures

The main outcomes for the DOORWAYS and BETTER project were service user and staff perceptions of the ward (VOICE and VOTE, respectively) and the health economic measure was CITRINE. All were developed in WPs 1 and 2.

Results

We developed reliable and valid measures of (1) the perceptions of inpatient care from the perspectives of service users and nurses (VOICE and VOTE) and (2) costs of interactions that were valued by service users (CITRINE). In the DOORWAYS project, after adjusting for legal status, we found weak evidence for benefit (standardised effect of –0.18, 95% CI 0.38 improvement to 0.01 deterioration;p = 0.062). There was only a significant benefit for involuntary patients following the staff training (N582, standardised effect of –0.35, 95% CI –0.57 to –0.12;p = 0.002; interactionp-value 0.006). VOTE scores did not change over time (standardised effect size of 0.04, 95% CI –0.09 to 0.18;p = 0.54). We found no evidence of an improvement in cost-effectiveness (estimated effect of £33, 95% CI –£91 to £146;p = 0.602), but resource allocation did change towards patient-perceived meaningful contacts by an average of £12 (95% CI –£76 to £98;p = 0·774). There were no significant differences between the triage and routine models of admission in terms of better perceptions by service users (estimated effect 0.77-point improvement in VOICE score on the triage ward;p = 0.68) or nurses (estimated effect of 1.68-point deterioration in VOTE on the triage ward;p = 0.38) or in terms of the cost of the length of care provided (£391 higher on triage;p = 0.77).

Strengths and limitations

We have developed measures using methods involving both service users and staff from mental health services. The measures were developed specifically for acute inpatient services and, therefore, cannot be assumed to be useful for other services. For instance, extensions of the measures are under construction for use in mother and baby units. The strength of the BETTER PATHWAYS and DOORWAYS projects is the large-scale data collection. However, we were testing specific services based in inner city areas and stretching to inner urban areas. It may be that different effects would be found in more rural communities or in different types of inpatient care.

Future work

Our database will be used to develop an understanding of the mediating and moderating factors for improving care quality.

Trial registration

Current Controlled Trials ISRCTN06545047.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 7. See the NIHR Journals Library website for further project information.

Cost-effectiveness of early intervention services for psychosis and fidelity to national policy implementation guidance

AIM

Early intervention services (EIS) for psychosis are being implemented, internationally. It is important to learn from established examples and define the components and intensity of services that provide good value for money. This study aims to assess the cost-effectiveness of EIS according to how closely they adhered to the recommendations of the English Department of Health 2001 Policy Implementation Guide (PIG).

METHODS

EIS from the National Eden Study were assessed using a measure of fidelity to the PIG that rated the presence or absence of 64 recommended items relating to team structure and practice. EIS were then classified into three groups: those with fidelity of 75-80%, 81-90% and 91-95%. Patient-level resource use and outcomes were measured 1 year following inception into the service; costs were calculated and combined with quality-adjusted life years (QALYs) gained.

RESULTS

At a threshold of £20 000 per QALY, the 81-90% fidelity group had a 56.3% likelihood of being the most cost-effective option followed by 75-80% fidelity at 35.8% and 91-95% fidelity group (7.9%).

CONCLUSIONS

The results from England suggest that striving to maximize fidelity may not be warranted, but that dropping below a certain level of fidelity may result in inefficient use of resources.

Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial

BACKGROUND

Intensive community treatment to reduce dependency on adolescent psychiatric inpatient care is recommended in guidelines but has not been assessed in a randomised controlled trial in the UK. We designed a supported discharge service (SDS) provided by an intensive community treatment team and compared outcomes with usual care.

METHODS

Eligible patients for this randomised controlled trial were younger than 18 years and had been admitted for psychiatric inpatient care in the South London and Maudsley NHS Foundation Trust. Patients were assigned 1:1 to either the SDS or to usual care by use of a computer-generated pseudorandom code with random permuted blocks of varying sizes. The primary outcome was number of inpatient bed-days, change in Strengths and Difficulties Questionnaire (SDQ) scores, and change in Children's Global Assessment Scale (CGAS) scores at 6 months, assessed by intention to treat. Cost-effectiveness was explored with acceptability curves based on CGAS scores and quality-adjusted life-years (QALYs) calculated from the three-level EuroQol measure of health-related quality of life (EQ-5D-3L), taking a health and social care perspective. This study is registered with the ISRCTN Registry, number ISRCTN82129964.

FINDINGS

Hospital use at 6 months was significantly lower in the SDS group than in the usual care group (unadjusted median 34 IQR 17-63 vs 50 days, 19-125, p=0·04). The ratio of mean total inpatient days for usual care to SDS was 1·67 (95% CI 1·02-2·81, p=0·04), which decreased to 1·65 (0·99-2·77, p=0·057) when adjusted for differences in hospital use before randomisation. Scores for SDQ and CGAS did not differ between groups. The cost-effectiveness acceptability curve based on QALYs showed that the probability of SDS being cost-effective compared with usual care was around 60% with a willingness-to-pay threshold of £20 000-30 000 per QALY, and that based on CGAS showed at least 58% probability of SDS being cost-effective compared with usual care irrespective of willingness to pay. We recorded no adverse events attributable to SDS or usual care.

INTERPRETATION

SDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies.

FUNDING

South London and Maudsley NHS Trust.

Improved Sleep, Diet, and Exercise in Adults with Serious Mental Illness: Results from a Pilot Self-Management Intervention

Compared to the general population, adults with serious mental illnesses have elevated rates of medical morbidity resulting in a reduced life expectancy of approximately 15 years. Chronic disease self-management programs for adults with serious mental and chronic medical illnesses show some promise in improving physical health-related outcomes, yet none of them address sleep quality. Poor sleep affects a majority of adults with serious mental illness and is robust risk factor for physical morbidity and premature mortality. This pilot project examined the impact of a 14-week educational and support group that included sleep quality as a cornerstone in promoting wellness and self-management in 78 adults with serious mental illness and poor health. Results provide preliminary data that the self-management program was associated with significant improvements in self-reported sleep quality at post-intervention. At 3-month follow-up, participants reported additional increases in sleep quality as well as in healthy diet and exercise frequency. Addressing sleep quality as part of self-management and wellness programs may be a viable approach to assist adults with chronic mental and physical illnesses to adopt health-promoting changes.

The economic cost of treatment-resistant depression in patients referred to a specialist service

BACKGROUND

Patients with treatment-resistant depression (TRD) suffer very significant morbidity and are at a disadvantage concerning optimal clinical management. There are high associated societal costs.

AIMS

A detailed analysis of health economic costs in the United Kingdom in a group manifesting a severe form of TRD in the 12 months before their participation in a major randomized controlled treatment trial.

METHODS

The sample consisted of 118 participants from the Tavistock Adult Depression Study. Recruitment was from primary care on the basis of current major depression disorder of at least 2 years' duration and two failed treatment attempts. Service utilization was assessed based on self-report and general practitioner (GP) medical records. Generalized linear models were used to identify predictors of cost.

RESULTS

All participants used GP services. Use of other doctors and practice nurses was also high. The mean total societal cost was £22 124, 80% of which was due to lost work and care required of families. Level of general functioning was found to be the most consistent predictor of costs.

CONCLUSIONS

Severe forms of TRD are associated with high costs in which unpaid care and lost work predominate. Treatments that improve functioning may reduce the large degree of burden.

Randomised controlled trial to improve health and reduce substance use in established psychosis (IMPaCT): cost-effectiveness of integrated psychosocial health promotion

BACKGROUND

There is mounting evidence that people with severe mental illness have unhealthy lifestyles, high rates of cardiovascular and metabolic diseases, and greater risk of early mortality. This study aimed to assess the cost-effectiveness of a health promotion intervention seeking to improve physical health and reduce substance use in people with psychosis.

METHODS

Participants with a psychotic disorder, aged 18-65 years old and registered on an enhanced care approach programme or equivalent were recruited from community mental health teams in six mental health trusts in England. Participants were randomisation to either standard community mental health team care (treatment as usual) or treatment as usual with an integrated health promotion intervention (IMPaCT). Cost-effectiveness and cost-utility analyses from health and social care and societal perspectives were conducted alongside a cluster randomised controlled trial. Total health and social care costs and total societal costs at 12 and 15 months were calculated as well as cost-effectiveness (incremental cost-effectiveness ratios and cost-effectiveness acceptability curves) at 15 months based on quality of life (SF-36 mental and physical health components, primary outcome measures) and quality adjusted life years (QALYs) using two measures, EQ-5D-3 L and SF-36. Data were analysed using bootstrapped regressions with covariates for relevant baseline variables.

RESULTS

At 12-15 months 301 participants had full data needed to be included in the economic evaluation. There were no differences in adjusted health and social care costs (£95, 95% CI -£1410 to £1599) or societal costs (£675, 95% CI -£1039 to £2388) between the intervention and control arms. Similarly, there were no differences between the groups in the SF-36 mental component (-0.80, 95% CI -3.66 to 2.06), SF-36 physical component (-0.68, 95% CI -3.01 to 1.65), QALYs estimated from the SF-36 (-0.00, -0.01 to 0.00) or QALYs estimated from the EQ-5D-3 L (0.00, 95% CI -0.01 to 0.02). Cost-effectiveness acceptability curves for all four outcomes and from both cost perspectives indicate that the probability of the health promotion intervention being cost-effective does not exceed 0.4 for willingness to pay thresholds ranging from £0-£50,000.

CONCLUSIONS

Alongside no evidence of additional quality of life/clinical benefit, there is also no evidence of cost-effectiveness.

TRIAL REGISTRATION

ISRCTN58667926 . Date retrospectively registered: 23/04/2010. Recruitment start date: 01/03/2010.

Economic evaluation of multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: A randomized controlled trial

BACKGROUND

A multi-centre RCT has shown that multidisciplinary rehabilitation treatment (MRT) is more effective in reducing fatigue over the long-term in comparison with cognitive behavioural therapy (CBT) for patients with chronic fatigue syndrome (CFS), but evidence on its cost-effectiveness is lacking.

AIM

To compare the cost-effectiveness of MRT versus CBT for patients with CFS from a societal perspective.

METHODS

A multi-centre randomized controlled trial comparing MRT with CBT was conducted among 122 patients with CFS diagnosed using the 1994 criteria of the Centers for Disease Control and Prevention and aged between 18 and 60 years. The societal costs (healthcare costs, patient and family costs, and costs for loss of productivity), fatigue severity, quality of life, quality-adjusted life-year (QALY), and cost-effectiveness ratios (ICERs) were measured over a follow-up period of one year. The main outcome of the cost-effectiveness analysis was fatigue measured by the Checklist Individual Strength (CIS). The main outcome of the cost-utility analysis was the QALY based on the EuroQol-5D-3L utilities. Sensitivity analyses were performed, and uncertainty was calculated using the cost-effectiveness acceptability curves and cost-effectiveness planes.

RESULTS

The data of 109 patients (57 MRT and 52 CBT) were analyzed. MRT was significantly more effective in reducing fatigue at 52 weeks. The mean difference in QALY between the treatments was not significant (0.09, 95% CI: -0.02 to 0.19). The total societal costs were significantly higher for patients allocated to MRT (a difference of €5,389, 95% CI: 2,488 to 8,091). MRT has a high probability of being the most cost effective, using fatigue as the primary outcome. The ICER is €856 per unit of the CIS fatigue subscale. The results of the cost-utility analysis, using the QALY, indicate that the CBT had a higher likelihood of being more cost-effective.

CONCLUSIONS

The probability of being more cost-effective is higher for MRT when using fatigue as primary outcome variable. Using QALY as the primary outcome, CBT has the highest probability of being more cost-effective.

TRIAL REGISTRATION

ISRCTN77567702.

Variations in the cost of formal and informal health care for patients with advanced chronic disease and refractory breathlessness: A cross-sectional secondary analysis

BACKGROUND

Refractory breathlessness in advanced chronic disease leads to high levels of disability, anxiety and social isolation. These result in high health-resource use, although this is not quantified.

AIMS

To measure the cost of care for patients with advanced disease and refractory breathlessness and to identify factors associated with high costs.

DESIGN

A cross-sectional secondary analysis of data from a randomised controlled trial.

SETTING/PARTICIPANTS

Patients with advanced chronic disease and refractory breathlessness recruited from three National Health Service hospitals and via general practitioners in South London.

RESULTS

Of 105 patients recruited, the mean cost of formal care was £3253 (standard deviation £3652) for 3 months. The largest contributions to formal-care cost were hospital admissions (>60%), and palliative care contributed <1%. When informal care was included, the total cost increased by >250% to £11,507 (standard deviation £9911). Increased patient disability resulting from breathlessness was associated with high cost (£629 per unit increase in disability score; p = 0.006). Increased breathlessness on exertion and the presence of an informal carer were also significantly associated with high cost. Patients with chronic obstructive pulmonary disease tended to have higher healthcare costs than other patients.

CONCLUSION

Informal carers contribute significantly to the care of patients with advanced disease and refractory breathlessness. Disability resulting from breathlessness is an important clinical cost driver. It is important for policy makers to support and acknowledge the contributions of informal carers. Further research is required to assess the clinical- and cost-effectiveness of palliative care interventions in reducing disability resulting from breathlessness in this patient group.

Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs

This cross-sectional study aimed to determine the prevalence and impact of depression on health care costs in patients with complex chronic pain. The sample included 1204 patients attending a tertiary pain management service for people with chronic disabling pain, unresponsive to medical treatment. As part of routine care, patients completed a web-based questionnaire assessing mental and physical health, functioning, and service use in the preceding 3 months. Depression was assessed using the 9-item Patient Health Questionnaire. Self-report health care utilisation was measured across 4 domains: general practitioner contacts, contacts with secondary/tertiary care doctors, accident and emergency department visits, and days hospitalised. The participation rate was 89%. Seven hundred and thirty-two patients (60.8%; 95% CI 58.0-63.6) met criteria for probable depression, and 407 (33.8%) met the threshold for severe depression. Patients with depression were more likely to be unable to work because of ill health and reported greater work absence, greater pain-related interference with functioning, lower pain acceptance, and more generalised pain. Mean total health care costs per 3-month period were £731 (95% CI £646-£817) for patients with depression, compared with £448 (95% CI £366-£530) for patients without depression. A positive association between severe depression and total health care costs persisted after controlling for key demographic, functional, and clinical covariates using multiple linear regression models. These findings reveal the extent, severity, and impact of depression in patients with chronic pain and make evident a need for action. Effective treatment of depression may improve patient health and functioning and reduce the burden of chronic pain on health care services.

Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design

Background

At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK.

Research questions

(1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention?

Methods

We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial.

Results

Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’sd = 0.34), after 6 months (Cohen’sd = 0.29) and after 12 months (Cohen’sd = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs.

Limitations

The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings.

Conclusions

(1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life.

Future research

Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression.

Trial registration

Current Controlled Trials ISRCTN34757603.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Barriers to access to treatment for mothers with postpartum depression in primary health care centers: a predictive model

OBJECTIVE

to develop a predictive model to evaluate the factors that modify the access to treatment for Postpartum Depression (PPD).

METHODS

prospective study with mothers who participated in the monitoring of child health in primary care centers. For the initial assessment and during 3 months, it was considered: sociodemographic data, gyneco-obstetric data, data on the services provided, depressive symptoms according to the Edinburgh Postpartum Depression Scale (EPDS) and quality of life according to the Short Form-36 Health Status Questionnaire (SF-36). The diagnosis of depression was made based on MINI. Mothers diagnosed with PPD in the initial evaluation, were followed-up.

RESULTS

a statistical model was constructed to determine the factors that prevented access to treatment, which consisted of: item 2 of EPDS (OR 0.43, 95%CI: 0.20-0.93) and item 5 (OR 0.48, 95%CI: 0.21-1.09), and previous history of depression treatment (OR 0.26, 95%CI: 0.61-1.06). Area under the ROC curve for the model=0.79; p-value for the Hosmer-Lemershow=0.73.

CONCLUSION

it was elaborated a simple, well standardized and accurate profile, which advises that nurses should pay attention to those mothers diagnosed with PPD, presenting low/no anhedonia (item 2 of EPDS), scarce/no panic/fear (item 5 of EPDS), and no history of depression, as it is likely that these women do not initiate treatment.

Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill

BACKGROUND

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

METHODS

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

RESULTS

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations (PABAK: 0.77; 95 % confidence interval (CI) = 0.71, 0.83), multiple psychiatric hospitalizations (PABAK = 0.50, 95 % CI = 0.41, 0.59), emergency department visits (PABAK: 0.77; 95 % CI = 0.71, 0.83), jail (PABAK: 0.74; 95 % CI = 0.68, 0.81), and income assistance (PABAK: 0.82; 95 % CI = 0.76, 0.87). Significant differences in under versus over reporting were also found.

CONCLUSIONS

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions. ISRCTN registry: 57595077 (Vancouver at Home Study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual); and 66721740 (Vancouver at Home study: Housing First plus Intensive Case management versus treatment as usual).

Childhood neglect predicts disorganization in schizophrenia through grey matter decrease in dorsolateral prefrontal cortex

OBJECTIVE

Psychosocial trauma during childhood is associated with schizophrenia vulnerability. The pattern of grey matter decrease is similar to brain alterations seen in schizophrenia. Our objective was to explore the links between childhood trauma, brain morphology and schizophrenia symptoms.

METHOD

Twenty-one patients with schizophrenia stabilized with atypical antipsychotic monotherapy and 30 healthy control subjects completed the study. Anatomical MRI images were analysed using optimized voxel-based morphometry (VBM). Childhood trauma was assessed with the Childhood Trauma Questionnaire, and symptoms were rated on the Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS) (disorganization, positive and negative symptoms). In the schizophrenia group, we used structural equation modelling in a path analysis.

RESULTS

Total grey matter volume was negatively associated with emotional neglect (EN) in patients with schizophrenia. Whole-brain VBM analyses of grey matter in the schizophrenia group revealed a specific inversed association between EN and the right dorsolateral prefrontal cortex (DLPFC). Path analyses identified a well-fitted model in which EN predicted grey matter density in DLPFC, which in turn predicted the disorganization score.

CONCLUSION

Our findings suggest that EN during childhood could have an impact on psychopathology in schizophrenia, which would be mediated by developmental effects on brain regions such as the DLPFC.

Understanding preventive health screening services use in persons with serious mental illness: how does integrated behavioral health primary care compare?

OBJECTIVE

People with serious mental illness have reduced life expectancy, in large part due to reduced access to medical services and underutilization of preventive health services. This is a cross-sectional study that compared preventive services use in an integrated behavioral health primary care clinic (IBHPC) with two existing community mental health programs.

METHODS

Participants completed questionnaires about preventive health services use that contained 33 questions about demographic clinical information, and use of preventive health services, from October 2010 to December 2012. Services examined included mammogram, Papanicolaou Test, prostate specific antigen, digital rectal exam, fecal occult blood test, and flexible sigmoidoscopy or colonoscopy; blood pressure, height and weight, cholesterol, and blood sugar for diabetes; and influenza immunization, Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) antibodies. A health service utilization score was developed and used as primary outcome for data analyses.

RESULTS

In the multivariate analyses female gender (p < 0.05), race/ethnicity (p = 0.01 for Asian, p = 0.04 for Hispanic/Latino, both compared to White), program type (p < 0.001), and having a primary care provider (p < 0.001) were significant predictors of higher services use. IBHPC was associated with higher overall service utilization compared to one community mental health program (p < 0.001) but was similar when compared another (p = 0.34). There was high variability in use of individual services among the clinical programs.

CONCLUSION

More studies are needed to examine the effectiveness of integrated care in improving use of health screening services. Characteristics of the clinic in relation to use of preventive services deserve further study.

A place to call home: study protocol for a longitudinal, mixed methods evaluation of two housing first adaptations in Sydney, Australia

BACKGROUND

This protocol describes a study evaluating two 'Housing First' programs, Platform 70 and Common Ground, presently being implemented in the inner-city region of Sydney, Australia. The Housing First approach prioritises housing individuals who are homeless in standard lease agreement tenancies as rapidly as possible to lock in the benefits from long-term accommodation, even where the person may not be seen as 'housing ready'.

METHODS/DESIGN

The longitudinal, mixed methods evaluation utilises both quantitative and qualitative data collected at baseline and 12-month follow-up time points. For the quantitative component, clients of each program were invited to complete client surveys that reported on several factors associated with chronic homelessness and were hypothesised to improve under stable housing, including physical and mental health status and treatment rates, quality of life, substance use patterns, and contact with the health and criminal justice systems. Semi-structured interviews with clients and stakeholders comprised the qualitative component and focused on individual experiences with, and perceptions of, the two programs. In addition, program data on housing stability, rental subsidies and support levels provided to clients by agencies was collected and will be used in conjunction with the client survey data to undertake an economic evaluation of the two programs.

DISCUSSION

This study will systematically evaluate the efficacy of a scatter site model (Platform 70) and a congregated model (Common Ground) of the Housing First approach; an examination that has not yet been made either in Australia or internationally. A clear strength of the study is its timing. It was designed and implemented as the programs in question themselves were introduced. Moreover, the programs were introduced when the Australian Government, with State and Territory support, began a more focused, coordinated response to homelessness and funded rapid expansion of innovative homelessness programs across the country, including Common Ground supportive housing developments.

Experience of primary care among homeless individuals with mental health conditions

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons’ needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.

Medicaid expansion: chronically homeless adults will need targeted enrollment and access to a broad range of services

Homeless adults may gain access to health services under the Affordable Care Act's Medicaid expansion, which takes effect in 2014. This study analyzed the health coverage, health status, and health services use of 725 chronically homeless adults with disabilities in eleven cities in the United States. Nearly three-quarters of the chronically homeless adults in this study with incomes below the threshold for the Medicaid expansion were not enrolled in Medicaid. Fifty-three percent were uninsured or relied solely on state or local assistance, and 21 percent had other coverage that included Department of Veterans Affairs health care. The findings on differences in health status and service use across groups suggest that the Medicaid expansion offers important opportunities to increase coverage and access to care for chronically homeless adults. There may be potential savings for states that expand Medicaid, as people transition from state and local assistance to more comprehensive services under Medicaid. Targeted outreach and assistance to enroll eligible homeless people will be necessary. A broad range of physical and mental health services will be required, including case management to coordinate services.

Comparisons of Costs between Black Caribbean and White British Patients with Advanced Multiple Sclerosis in the UK

Background. Multiple sclerosis (MS) is now more common among black and minority ethnic groups in the UK but little is known about the costs of care amongst different ethnic groups. Objective. This study examined and compared service use and costs for people severely affected with MS from Black Caribbean (BC) and White British (WB) backgrounds in the UK and identified predictors of cost for both groups. Method. Population-based cross-sectional study of 43 BC and 43 WB patients with MS (EDSS ≥ 6) and their informal caregivers recruited from an MS service in southeast London. Interviews collected data on health and social service use and informal care support. Costs were calculated using UK unit cost data. Using regression analyses we compared costs between the ethnic groups and identified possible predictors of cost. Results. The mean (SD) costs for the WB and BC groups were £ 25,778 ( £ 39,387) and £ 23,186 ( £ 30,433), respectively. Results identified no significant difference in total cost between the two ethnic groups. The EDSS score alone was a significant predictor of cost. Conclusion. Similar costs between ethnic groups indicate that with regard to this MS service and geographical area, access to care was not affected by ethnicity.

Childhood sexual abuse increases risk of auditory hallucinations in psychotic disorders

BACKGROUND/AIMS

Previous studies point to an association between childhood sexual abuse (CSA) and auditory hallucinations (AH). However, methodological issues limit the strength of these results. Here we compared childhood abuse between psychotic disorder patients and healthy control subjects using a reliable measure of abuse, and assessed the relationship between CSA and AH.

METHODS

114 psychotic disorder patients and 81 healthy control subjects were administered the Structured Clinical Interview of the DSM-IV (SCID) and the Childhood Trauma Questionnaire (CTQ). We compared the severity of abuse between groups, and tested the relationship between different types of childhood abuse and specific psychotic symptoms.

RESULTS

Psychotic patients reported more childhood abuse than controls (p<.001). Psychotic patients with a history of AH reported significantly more sexual, emotional, and physical abuse than patients without a history of AH (p<.05). Emotional and physical abuse, in the absence of sexual abuse, did not lead to a higher rate of AH. Finally, reports of childhood abuse did not increase the risk of any form of hallucination other than AH or of any form of delusion.

CONCLUSIONS

These results suggest that childhood abuse, especially childhood sexual abuse, shapes the phenotype of psychotic disorders by conferring a specific risk for AH.

Can an epilepsy nurse specialist-led self-management intervention reduce attendance at emergency departments and promote well-being for people with severe epilepsy? A non-randomised trial with a nested qualitative phase

Objectives

To (1) describe the characteristics and service use of people with established epilepsy (PWE) who attend the emergency department (ED); (2) evaluate the economic impact of PWE who attend the ED; (3) determine the effectiveness and cost-effectiveness of an epilepsy nurse specialist (ENS)-led self-management intervention plus treatment as usual (TAU) compared with TAU alone in reducing ED use and promoting well-being; (4) describe patients' views of the intervention; and (5) explore their reasons for attending the ED.

Design

Non-randomised trial with nested qualitative study.

Setting

The EDs of three inner London hospitals. The EDs each offer similar services and support a similar local population, which made a comparison of patient outcomes reasonable.

Participants

Adults diagnosed with epilepsy for ≥ 1 year were prospectively identified from the EDs by presenting symptom/discharge diagnosis. We recruited 85 of 315 patients with 44 forming the intervention group and 41 the comparison group.

Intervention

Intervention participants were offered two one-to-one outpatient sessions delivered by an ENS who aimed to optimise self-management skills and knowledge of appropriate emergency service use. The first session lasted for 45–60 minutes and the second for 30 minutes.

Main outcome measures

The primary outcome was the number of ED visits that participants reported making over the 6 months preceding the 12-month follow-up. Secondary outcomes were visits reported at the 6-month follow-up and scores on psychosocial measures.

Results

In the year preceding recruitment, the 85 participants together made 270 ED visits. The frequency of their visits was positively skewed, with 61% having attended multiple times. The mean number of visits per participant was 3.1 [standard deviation (SD) 3.6] and the median was two (interquartile range 1–4). Mean patient service cost was £2355 (SD £2455). Compared with findings in the general epilepsy population, participants experienced more seizures and had greater anxiety, lower epilepsy knowledge and greater perceived stigma. Their outpatient care was, however, consistent with National Institute for Health and Clinical Excellence recommendations. In total, 81% of participants were retained at the 6- and 12-month follow-ups, and 80% of participants offered the intervention attended. Using intention-to-treat analyses, including those adjusted for baseline differences, we found no significant effect of the intervention on ED use at the 6-month follow-up [adjusted incidence rate ratio (IRR) 1.75, 95% confidence interval (CI) 0.93 to 3.28] or the 12-month follow-up (adjusted IRR 1.92, 95% CI 0.68 to 5.41), nor on any psychosocial outcomes. Because they spent less time as inpatients, however, the average service cost of intervention participants over follow-up was less than that of TAU participants (adjusted difference £558, 95% CI –£2409 to £648). Lower confidence in managing epilepsy and more felt stigma at baseline best predicted more ED visits over follow-up. Interviews revealed that patients generally attended because they had no family, friend or colleague nearby who had the confidence to manage a seizure. Most participants receiving the intervention valued it, including being given information on epilepsy and an opportunity to talk about their feelings. Those reporting most ED use at baseline perceived the most benefit.

Conclusions

At baseline, > 60% of participants who had attended an ED in the previous year had reattended in the same year. In total, 50% of their health service costs were accounted for by ED use and admissions. Low confidence in their ability to manage their epilepsy and a greater sense of stigma predicted frequent attendance. The intervention did not lead to a reduction in ED use but did not cost more, partly because those receiving the intervention had shorter average hospital stays. The most common reason reported by PWE for attending an ED was the lack of someone nearby with sufficient experience of managing a seizure. Those who attended an ED frequently and received the intervention were more likely to report that the intervention helped them. Our findings on predictors of ED use clarify what causes ED use and suggest that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency savings generated.

Trial registration

Current Controlled Trials ISRCTN06469947.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 1, No. 9. See the HSDR programme website for further project information.

Self-reported health and physical activity among community mental healthcare users

The aim of the study was to survey the self-reported health and physical activity in a sample of community mental healthcare users in a city of Sweden. The study was conducted through a cross-sectional design with participants requested to fill out a self-report questionnaire. Participants (n = 103) were persons with psychiatric disabilities living in residential psychiatric settings and/or participating in daily activities provided by community mental healthcare services. The results showed that the group is affected with serious risk factors, such as high body mass index, low rated extent and frequency of physical activity and low self-estimated general state of health. Even though some difficulties associated with the answering process of this questionnaire emerged, these self-reported results clearly confirm the fact that persons with psychiatric disabilities constitute a vulnerable group in need for health-promoting caring activities and interventions.

Reduced gray matter volume in psychotic disorder patients with a history of childhood sexual abuse

Childhood trauma is associated with smaller gray matter volume, similar to the pattern seen in psychotic disorders. We explored the relationship between childhood abuse, psychosis, and brain volume in a group of 60 individuals with a psychotic disorder and 26 healthy control subjects. We used voxel-based morphometry (VBM) to quantify gray and white matter volume and the Childhood Trauma Questionnaire (CTQ) to measure childhood abuse. Within the psychotic disorder group, total gray matter volume was inversely correlated with the severity of childhood sexual abuse (r=-.34, p=.008), but not the other types of abuse. When the 24 patients with sexual abuse were compared with demographically matched samples of 23 patients without sexual abuse and 26 control subjects, only patients with a history of sexual abuse had reduced total gray matter volume (t(48)=2.3, p=.03; Cohen's d=.63). Voxel-based analysis revealed a cluster in the prefrontal cortex where volume was negatively correlated with sexual abuse severity. Voxel based comparison of the three matched groups revealed a similar pattern of results, with widespread reductions in psychosis patients with sexual abuse relative to controls that were not found in psychosis patients without sexual abuse. These findings indicate that some of the variance of gray matter volume in psychotic disorders can be explained by a history of sexual abuse.

Developing a tool for collecting and costing activity data on psychiatric inpatient wards

BACKGROUND.

Increasing therapeutic inpatient activities may improve the quality and outcomes of care. Evaluation of these interventions is necessary including assessment of cost-effectiveness. The aim of this paper is to describe the development and reliability of a tool to collect information on care contacts and therapeutic activities of patients on inpatient wards.

METHOD.

The development of the tool consisted of: 1) literature review, 2) interviews with staff, 3) expert consultation, 4) feasibility study, 5) focus groups with staff members, and 6) reliability tests. Service use data were collected with the tool and costs calculated.

RESULTS.

Service users' reported more use of activities than that contained in case notes during a 7-day period. This resulted in a cost difference of £10 per person. Case notes had more one-to-one nursing contacts, with a cost difference of £4 per person. One-day data showed less nurse contact time reported by participants compared to observational data (p < 0.001) but similar use of activities. Costs were £46 for the tool and £67 for the observational data.

CONCLUSIONS.

This tool is a good source of information on the number of activities attended by service users and contacts with psychiatrists. There is some disagreement with other sources of information on interactions between service users and nurses, possibly reflecting different definitions of a ‘meaningful contact’. This does not have a major impact on cost given that for much of the care received there is reasonable agreement.

Cost-effectiveness of counselling, graded-exercise and usual care for chronic fatigue: evidence from a randomised trial in primary care

BACKGROUND

Fatigue is common and has been shown to result in high economic costs to society. The aim of this study is to compare the cost-effectiveness of two active therapies, graded-exercise (GET) and counselling (COUN) with usual care plus a self-help booklet (BUC) for people presenting with chronic fatigue.

METHODS

A randomised controlled trial was conducted with participants consulting for fatigue of over three months' duration recruited from 31 general practices in South East England and allocated to one of three arms. Outcomes and use of services were assessed at 6-month follow-up. The main outcome measure used in the economic evaluation was clinically significant improvements in fatigue, measured using the Chalder fatigue scale. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves.

RESULTS

Full economic and outcome data at six months were available for 163 participants; GET = 51, COUN = 58 and BUC = 54. Those receiving the active therapies (GET and COUN) had more contacts with care professionals and therefore higher costs, these differences being statistically significant. COUN was more expensive and less effective than the other two therapies. The incremental cost-effectiveness ratio of GET compared to BUC was equal to £987 per unit of clinically significant improvement. However, there was much uncertainty around this result.

CONCLUSION

This study does not provide a clear recommendation about which therapeutic option to adopt, based on efficiency, for patients with chronic fatigue. It suggests that COUN is not cost-effective, but it is unclear whether GET represents value for money compared to BUC. Clinical Trial Registration number at ISRCTN register: 72136156.

Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis

Background

The PACE trial compared the effectiveness of adding adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET), to specialist medical care (SMC) for patients with chronic fatigue syndrome. This paper reports the relative cost-effectiveness of these treatments in terms of quality adjusted life years (QALYs) and improvements in fatigue and physical function.

Methods

Resource use was measured and costs calculated. Healthcare and societal costs (healthcare plus lost production and unpaid informal care) were combined with QALYs gained, and changes in fatigue and disability; incremental cost-effectiveness ratios (ICERs) were computed.

Results

SMC patients had significantly lower healthcare costs than those receiving APT, CBT and GET. If society is willing to value a QALY at £30,000 there is a 62.7% likelihood that CBT is the most cost-effective therapy, a 26.8% likelihood that GET is most cost effective, 2.6% that APT is most cost-effective and 7.9% that SMC alone is most cost-effective. Compared to SMC alone, the incremental healthcare cost per QALY was £18,374 for CBT, £23,615 for GET and £55,235 for APT. From a societal perspective CBT has a 59.5% likelihood of being the most cost-effective, GET 34.8%, APT 0.2% and SMC alone 5.5%. CBT and GET dominated SMC, while APT had a cost per QALY of £127,047. ICERs using reductions in fatigue and disability as outcomes largely mirrored these findings.

Conclusions

Comparing the four treatments using a health care perspective, CBT had the greatest probability of being the most cost-effective followed by GET. APT had a lower probability of being the most cost-effective option than SMC alone. The relative cost-effectiveness was even greater from a societal perspective as additional cost savings due to reduced need for informal care were likely.

Long-term impact of war on healthcare costs: an eight-country study

Objective

Exposure to war can negatively affect health and may impact on healthcare costs. Estimating these costs and identifying their predictors is important for appropriate service planning. We aimed to measure use of health services in an adult population who had experienced war in the former-Yugoslavia on average 8 years previously, and to identify characteristics associated with the use and costs of healthcare.

Method

War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, FYR Macedonia, and Serbia were recruited through a random walk technique. Refugees in Germany, Italy and the UK were contacted through registers, organisations and networking. Current service use was measured for the previous three months and combined with unit costs for each country for the year 2006/7. A two-part approach was used, to identify predictors of service use with a multiple logistic regression model and predictors of cost with a generalised linear regression model.

Results

3,313 participants were interviewed in Balkan countries and 854 refugees in Western European countries. In the Balkan countries, traumatic events and mental health status were related to greater service use while in Western countries these associations were not found. Participants in Balkan countries with post traumatic stress disorder (PTSD) had costs that were 63% higher (p = 0.005) than those without PTSD. Distress experienced during the most traumatic war event was associated with higher costs (p = 0.013). In Western European countries costs were 76% higher if non-PTSD anxiety disorders were present (0.027) and 63% higher for mood disorders (p = 0.006).

Conclusions

War experiences and their effects on mental health are associated with increased health care costs even many years later, especially for those who stayed in the area of conflict. Focussing on the mental health impact of war is important for many reasons including those of an economic nature.

Predictors of health services utilization among persons with psychiatric disabilities engaged in supported independent housing

OBJECTIVE

Persons with psychiatric disabilities are at greater risk for medical comorbidity, and prior research suggests these persons may underutilize health services. In response, this study examined the impact of engagement in psychiatric rehabilitation services, including case management, on utilization of general health services among persons with psychiatric disabilities engaged in supported housing, while controlling for demographic and clinical characteristics.

METHODS

Poisson regression analyses were used to examine the impact of socio-demographic, clinical, and service characteristics on reported utilization of general health services in the past year.

RESULTS

Findings indicated supported housing residents receiving case management coupled with weekly contact with residential support services visited a general health practitioner more frequently than those with less support services.

CONCLUSIONS AND IMPLICATIONS

Study results suggest psychiatric rehabilitation services provided to persons in the context of safe and affordable housing may represent an important mechanism for enabling persons with psychiatric disorders to access needed medical care.

Preventive medical services use among community mental health patients with severe mental illness:the influence of gender and insurance coverage

INTRODUCTION

This study examines predictors of reduced preventive health service use in patients with severe mental illness by examining psychiatric diagnoses and demographic factors.

METHOD

Of 387 patients approached in 4 community mental health clinics regarding their preventive health services use from January 2005 to May 2007, 234 (60.5%) were interviewed. Of those participants interviewed, 221 had a DSM-IV-TR diagnosis of (1) primary psychotic disorder (schizophrenia or schizoaffective disorder), (2) bipolar disorder, or (3) recurrent major depressive disorder. Psychiatric disorders and demographic factors that predicted high service utilization were analyzed using analysis of variance and χ² tests.

RESULTS

In the linear predictive model, use of preventive services was not statistically different among the 3 diagnostic groups. Participants with primary psychotic disorder used a similar number of preventive services compared to those with bipolar disorder and major depression. Women used more services than men (P < .01), and individuals with health insurance used more than uninsured participants (P < .001).

CONCLUSION

Male gender and not having medical insurance were predictive of lower preventive health service use in this sample of patients with severe mental illness. Further research is needed to replicate these findings and to improve use of preventive health services in people with severe mental illness.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

The economic costs of progressive supranuclear palsy and multiple system atrophy in France, Germany and the United Kingdom

Progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) are progressive disabling neurological conditions usually fatal within 10 years of onset. Little is known about the economic costs of these conditions. This paper reports service use and costs from France, Germany and the UK and identifies patient characteristics that are associated with cost. 767 patients were recruited, and 760 included in the study, from 44 centres as part of the NNIPPS trial. Service use during the previous six months was measured at entry to the study and costs calculated. Mean six-month costs were calculated for 742 patients. Data on patient sociodemographic and clinical characteristics were recorded and used in regression models to identify predictors of service costs and unpaid care costs (i.e., care from family and friends). The mean six-month service costs of PSP were €24,491 in France, €30,643 in Germany and €25,655 in the UK. The costs for MSA were €28,924, €25,645 and €19,103 respectively. Unpaid care accounted for 68-76%. Formal and unpaid costs were significantly higher the more severe the illness, as indicated by the Parkinson's Plus Symptom scale. There was a significant inverse relationship between service and unpaid care costs.

Measuring use of services for mental health problems in epidemiological surveys

The use of services for mental problems is generally reported as being relatively low. However, the methods used for data collection in surveys may have influenced the quality of self-reported service use. This study compares the information on recourse to physicians for mental problems reported in different sections of a survey conducted in six European countries. Thus, 5545 respondents were asked questions on contacts with physicians at least twice: (1) after the symptoms checklist in any completed diagnostic section, and (2) in a section devoted to use of care for mental problems. Of these 39.3% reported contacts with physicians about mental problems in the diagnostic sections, whereas 29.5% did so in the use-of-care section. Inconsistencies concerned 20.1% of participants, among whom those reporting consultations in diagnostic sections without reporting them in the use-of-care section represented the majority (74.4%). Multiple logistic regression analysis revealed that age, marital status, educational level and country were associated with under-reporting in the use-of-care section, as well as having mood or sleep problems. In conclusion, services used for mental health reasons when measured through a question referring to use of care due to the presence of a mental problem may underestimate the care people received for their problems.

Mental health economics: current methodological issues

BACKGROUND

Investment in innovative mental health care services requires the use of scarce resources that could be used in alternative ways. Economic evaluation is essential to ensure that such an investment is appropriately compared with investment elsewhere.

METHOD

A non-systematic review of mental health evaluations identifies key methodological issues pertaining to economic studies.

RESULTS

Economic evaluations require the measurement and combination of costs and outcomes, and clarity about how this measurement is undertaken is required. Regarding costs, important considerations relate to the perspective to be taken (e.g., health service or societal), method of measurement (patient self-report or use of databases) and valuation (actual costs, fees or expenditure). Decision makers frequently need to compare evidence both within and between clinical areas and therefore there is a tension between the use of condition specific and generic outcome measures. Quality-adjusted life years are frequently used in economic evaluations, but their appropriateness in mental health care studies is still debated.

CONCLUSIONS

Economic evaluations in the area of mental health care are increasing in number and it is essential that researchers continue to develop and improve methods used to conduct such studies.

Racial and ethnic service use disparities among homeless adults with severe mental illnesses receiving ACT

OBJECTIVE

Case management-based interventions aimed at improving quality of care have the potential to narrow racial and ethnic disparities among people with chronic illnesses. The aim of this study was to assess the equity effects of assertive community treatment (ACT), an evidence-based case management intervention, among homeless adults with severe mental illness.

METHODS

This study used baseline, three-, and 12-month data for 6,829 black, Latino, and white adults who received ACT services through the ACCESS study (Access to Community Care and Effective Services and Support). Zero-inflated Poisson random regression models were used to estimate the adjusted probability of use of outpatient psychiatric services and, among service users, the intensity of use. Odds ratios and rate ratios (RRs) were computed to assess disparities at baseline and over time.

RESULTS

No disparities were found in probability of use at baseline or over time. Compared with white users, baseline intensity of use was lower for black users (RR=.89; 95% confidence interval [CI]=.83-.96) and Latino users (RR=.65; CI=.52-.81]). Intensity did not change over time for whites, but it did for black and Latino users. Intensity increased for blacks between baseline and three months (RR=1.11, CI=1.06-1.17]) and baseline and 12 months (RR=1.17, CI=1.11-1.22]). Intensity of use dropped for Latinos between baseline and three months (RR=.83, CI=.70-.98).

CONCLUSIONS

Receipt of ACT was associated with a reduction in service use disparities for blacks but not for Latinos. Findings suggest that ACT's equity effects differ depending on race-ethnicity.

Enhancing Adoptive Parenting: A Cost-Effectiveness Analysis

BACKGROUND

  Children adopted from care often exhibit behavioural difficulties. There is however limited cost-effectiveness evidence regarding different interventions to address this. This paper reports a cost-effectiveness analysis of parenting programmes for these children.

METHOD

  Adoptive parents of children aged between 3 and 8 years participated in home-based, manualised, parenting programmes delivered by trained family social workers. The adopters were randomly allocated to one of two interventions (n = 19) or to a 'services as usual' control group (n = 18). Baseline, immediate post-intervention and 6-month follow-ups were assessed by questionnaires and adopter interviews. Economic costs were calculated.

RESULTS

  At 6-month follow-up, a significant difference (p < .007) was found for 'satisfaction with parenting' in favour of the intervention group. No significant differences were found on child measures between the combined intervention groups and control group, adjusting for baseline scores. The mean costs for the combined intervention group were £1528 higher than for the control group at the post-intervention point, which was statistically significant (95% CI, £67 to £2782). However, over the entire follow-up period the difference (£1652) was not statistically significant (-£1709 to £4268). The cost-effectiveness analysis showed that costs of £731 would be incurred to achieve a point improvement in satisfaction with parenting compared to routine care by the end of treatment, whilst the figure was £337 for a point improvement by the 6-month follow-up.

CONCLUSIONS

  Findings suggest that a home-based parenting programme for adopters caring for difficult children in the first 18 months of placement may be cost-effective in enhancing satisfaction with parenting, but not in reducing child behavioural problems, compared with 'services-as-usual'.

Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS

BACKGROUND

Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics.

OBJECTIVE

This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems.

METHODS

Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance.

RESULTS

At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past 6 months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance.

CONCLUSIONS

Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.

Supported employment: randomised controlled trial

BACKGROUND

There is evidence from North American trials that supported employment using the individual placement and support (IPS) model is effective in helping individuals with severe mental illness gain competitive employment. There have been few trials in other parts of the world.

AIMS

To investigate the effectiveness and cost-effectiveness of IPS in the UK.

METHOD

Individuals with severe mental illness in South London were randomised to IPS or local traditional vocational services (treatment as usual) (ISRCTN96677673).

RESULTS

Two hundred and nineteen participants were randomised, and 90% assessed 1 year later. There were no significant differences between the treatment as usual and intervention groups in obtaining competitive employment (13% in the intervention group and 7% in controls; risk ratio 1.35, 95% CI 0.95-1.93, P = 0.15), nor in secondary outcomes.

CONCLUSIONS

There was no evidence that IPS was of significant benefit in achieving competitive employment for individuals in South London at 1-year follow-up, which may reflect suboptimal implementation. Implementation of IPS can be challenging in the UK context where IPS is not structurally integrated with mental health services, and economic disincentives may lead to lower levels of motivation in individuals with severe mental illness and psychiatric professionals.

Cost-effectiveness of an early intervention service for people with psychosis

BACKGROUND

There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness.

AIMS

To compare the costs and cost-effectiveness of an early intervention service in London with standard care.

METHOD

Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness.

RESULTS

A total of 144 people were randomised. Total mean costs were 11,685 pounds sterling in the early intervention group and 14,062 pounds sterling in the standard care group, with the difference not being significant (95% CI -8128 pounds sterling to 3326 pounds sterling). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective.

CONCLUSIONS

Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.

The hidden cost of chronic fatigue to patients and their families

BACKGROUND

Nearly 1 in 10 in the population experience fatigue of more than six months at any one time. Chronic fatigue is a common reason for consulting a general practitioner, and some patients report their symptoms are not taken seriously enough. A gap in perceptions may occur because doctors underestimate the impact of fatigue on patients' lives. The main aim of the study is to explore the economic impact of chronic fatigue in patients seeking help from general practitioners and to identify characteristics that explain variations in costs.

METHODS

The design of study was a survey of patients presenting to general practitioners with unexplained chronic fatigue. The setting were 29 general practice surgeries located in the London and South Thames regions of the English National Health Service. Use of services over a six month period was measured and lost employment recorded. Regression models were used to identify factors that explained variations in these costs.

RESULTS

The mean total cost of services and lost employment across the sample of 222 patients was 3878 pounds for the six-month period. Formal services accounted for 13% of this figure, while lost employment accounted for 61% and informal care for 26%. The variation in the total costs was significantly related to factors linked to the severity of the condition and social functioning.

CONCLUSIONS

The economic costs generated by chronic fatigue are high and mostly borne by patients and their families. Enquiry about the functional consequences of fatigue on the social and occupational lives of patients may help doctors understand the impact of fatigue, and make patients feel better understood.