16 Outcomes of a novel 5-week individualized multidisciplinary outpatient (day-patient) treatment programme for functional (psychogenic) neurological symptoms

Aim

We report the results of a novel 5-week treatment programme, delivered by a multi-disciplinary team, with individualised sessions to treat functional neurological symptoms in a neuropsychiatric outpatient setting. The primary aims of this MDT programme were to (a) reduce symptoms (b) improve health and social functioning (c) improve functional performance (d) improve health status.

Method

Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational therapy, education and family meetings. Outcome measures were collected at the beginning and end of treatment and at a 6 month face to face follow-up. These were both patient and clinician reported. The aims were assessed by the following measures: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg, CGI); health and social functioning (HONOS, WSAS); functional performance (COPM); and improvements in health status (EQ5DL). Results: Analyses were conducted on 78 patients who started and completed the programme and attended a 6 month face to face review. There were high baseline levels of disability compared to EQ5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression (PHQ9 >10) and 71% met the IAPT caseness threshold for anxiety (GAD7 >8). A repeated measures Freidman’s ANOVA over 3 timepoints (admission, discharge and 6 month follow-up) followed by Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6 months follow up. These improvements were seen in in somatic symptoms (PHQ15), depression (PHQ9) and anxiety (GAD7) symptoms, health and social functioning (HONOS), functional performance (COPM), health status (EQ5D-5L and EQ5D-EL VAS) and patient ratings of clinical global improvement (CGI). There was a high acceptance of this neuropsychiatry led MDT programme indicated by the patient reported visual analogue scale for benefit of programme averaging at 90%.

Conclusion

An MDT can effectively deliver an outpatient programme for FNS which can serve as an alternative to an inpatient programme for patients with fewer or no nursing needs, for those whose preference is an outpatient setting or for those seeking to minimise disruption to work or family life. There may be potential cost reductions for institutions compared to inpatient treatment depending on local calculations. In the future, earlier identification and treatment of co-morbidities may modify some predisposing and perpetuating factors.

Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD)

Aim

We report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status.

Methods

Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI).

Results

Analyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI).

Conclusion

An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-09874-5) contains supplementary material, which is available to authorized users.

Subarachnoid haemorrhage guidelines and clinical practice: a cross-sectional study of emergency department consultants' and neurospecialists' views and risk tolerances

OBJECTIVES

To establish if emergency medicine and neuroscience specialist consultants have different risk tolerances for investigation of suspected spontaneous subarachnoid haemorrhage (SAH), and to establish if their risk-benefit appraisals concur with current guidelines.

SETTING

4 major neuroscience centres in London.

PARTICIPANTS

58 consultants in emergency medicine and neuroscience specialities (neurology, neurosurgery and neuroradiology) participated in an anonymous survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the highest stated acceptable risk of missing SAH in the neurologically intact patient presenting with sudden onset headache. Secondary outcome measures included agreement with guideline recommendations, risk/benefit appraisal and required performance of diagnostic tests, including lumbar puncture.

RESULTS

Emergency department clinicians accepted almost 3 times the risk of a missed SAH diagnosis compared with the neuroscience specialists (2.8% vs 1.1%; p=0.02), were more likely to accept a higher risk of missed diagnosis for the benefit of a non-invasive test (p=0.04) and were more likely to disagree with current published guidelines stipulating the need for LP in all CT-negative cases (p=0.001).

CONCLUSIONS

Divergence from recognised procedures for SAH investigation is often criticised and attributed to a lack of knowledge of guidelines. This study indicates that divergence from guidelines may be explained by alternative risk-benefit appraisals made by doctors with their patients. Guideline recommendations may gain wider acceptance if they accommodate the requirements of the doctors and patients using them. Further study of clinical risk tolerance may help explain patterns of diagnostic test use and other variations in healthcare delivery.

The Gilles de la Tourette syndrome-quality of life scale (GTS-QOL): development and validation

BACKGROUND

Gilles de la Tourette syndrome (GTS) is a chronic neuropsychiatric disorder which has a significant detrimental impact on the health-related quality of life (HR-QOL) of patients. However, no patient-reported HR-QOL measures have been developed for this population.

OBJECTIVE

The development and validation of a new scale for the quantitative assessment of HR-QOL in patients with GTS.

METHODS

In stage 1 (item generation), a pool of 40 potential scale items was generated based on interviews with 133 GTS outpatients, literature review, and consultation with experts. In stage 2 (scale development), these items were administered to a sample of 192 GTS outpatients. Standard statistical methods were used to develop a rating scale satisfying criteria for acceptability, reliability, and validity. In stage 3 (scale evaluation), the psychometric properties of the resulting scale were tested in a second sample of 136 subjects recruited through the UK-Tourette Syndrome Association.

RESULTS

Response data analysis and item reduction methods led to a final 27-item GTS-specific HR-QOL scale (GTS-QOL) with four subscales (psychological, physical, obsessional, and cognitive). The GTS-QOL demonstrated satisfactory scaling assumptions and acceptability; both internal consistency reliability and test-retest reliability were high (Cronbach alpha > or =0.8 and intraclass correlation coefficient > or =0.8); validity was supported by interscale correlations (range 0.5-0.7), confirmatory factor analysis, and correlation patterns with other rating scales and clinical variables.

CONCLUSIONS

The Gilles de la Tourette syndrome (GTS)-specific health-related quality of life (HR-QOL) scale (GTS-QOL) is proposed as a new disease-specific patient-reported scale for the measurement of HR-QOL in patients with GTS, taking into account the complexity of the clinical picture of GTS.

Testing the validity of the PDQ-39 in patients with MSA

We assessed the validity of the PDQ-39, a disease-specific health-related quality of life instrument for patients with Parkinson's disease, in patients with multiple system atrophy (MSA). Two hundred and seventy-nine patients completed the PDQ-39, the EQ-5D, the Hospital Anxiety and Depression Scale, and scales of life satisfaction and disease severity. Ceiling and floor effects were noted in some dimensions, and Mobility was skewed towards the severe end of the spectrum. Apart from the dimension of Social Support, all dimensions had high internal consistency. The factor structure of the PDQ-39 in MSA was stable, and convergent and divergent validity with other measures of quality of life and mental health were good. However, many of the specific features of MSA are not reflected in the PDQ-39. Higher order factor analysis did not support the use of a single summary index. We conclude that the PDQ-39 has only limited validity in patients with MSA.

Measuring quality of life in PSP: the PSP-QoL

OBJECTIVE

To develop a new patient-reported outcome measure for progressive supranuclear palsy (PSP) and to test its psychometric properties.

METHODS

First, the authors generated a pool of potential scale items from in-depth patient interviews. Second, the authors administered these items, in the form of a questionnaire, to a sample of people with PSP and traditional psychometric methods were used to develop a rating scale satisfying standard criteria for reliability and validity. Third, the authors examined the psychometric properties of the rating scale in a second sample.

RESULTS

In stage 1, a pool of 87 items was generated from 27 patient interviews. In stage 2, a scale with two subscales (physical, 22 items; mental, 23 items), satisfying standard criteria for reliability and validity, was developed from the response data of 225 patients with PSP. In stage 3, the scale was examined in 188 people with PSP. Missing data were low, scores in both subscales were evenly distributed, floor and ceiling effects were small. Reliability was high (Cronbach's alpha 0.93, 0.95; test-retest 0.95, 0.92). Validity was supported by the interscale intercorrelation (0.60), factor analysis, and the magnitude and pattern of correlations with four other rating scales, disease severity, and disease duration. The psychometric properties of the new scale were similar in the United Kingdom and North America, and in clinic- and community-based samples studied.

CONCLUSIONS

The Progressive Supranuclear Palsy Quality of Life scale (PSP-QoL) may be a helpful patient-reported scale for clinical trials and studies in PSP.

Measuring health-related quality of life in patients with progressive supranuclear palsy

The development of psychometrically sound health-related quality of life (Hr-QoL) instruments has made it possible to assess subjectively experienced Hr-QoL quantitatively, and to incorporate Hr-QoL as a measure in medical research and clinical trials. Hr-QoL in patients with progressive supranuclear palsy (PSP) has been measured using generic (not disease-specific) instruments, or Parkinson's disease-specific scales. We give an overview of the development of a disease-specific Hr-QoL instrument for patients with PSP. Based on interviews with 27 patients with PSP a preliminary Hr-QoL instrument was developed and administered to over 300 people with PSP in the UK and US. Following psychometric analysis a rating scale with a physical and a mental subscale emerged. In this patient sample, both subscales satisfied criteria for scaling assumptions, acceptability, reliability and validity (correlations with other measures consistent with a priori hypotheses). The psychometric properties of this questionnaire are undergoing further evaluation.

Psychopathological profile in patients with severe bilateral hippocampal atrophy and temporal lobe epilepsy: evidence in support of the Geschwind syndrome?

Bilateral symmetrical hippocampal atrophy (BHA) has been implicated as a possible causal element in various neuropsychiatric disorders, in particular depressive disorder and schizophrenia. To test the hypothesis that bilateral symmetrical severe volume loss of the hippocampi is of causal relevance to these psychiatric syndromes rather than an epiphenomenon we assessed the psychopathology in a group of patients with temporal lobe epilepsy (TLE) and very severe bilateral symmetrical hippocampal atrophy and compared it with that of a patient control group. Patients with TLE and hippocampal volumes smaller than three standard deviations below the mean of a control population were identified and compared with a matched patient population with normal hippocampal volumes. Psychopathology was assessed by blinded trained psychiatrists using the Present State Examination and Neurobehavioral Inventory. The prevalence of psychiatric syndromes was high in both patient groups; however, there was no significant difference between the two groups. With use of the more specific Neurobehavioral Inventory a psychopathological pattern reminiscent of the Geschwind syndrome emerged when patients with BHA were characterized by caregivers. While BHA does not result in an increased prevalence of specific psychiatric syndromes, specific symptoms that characterize the Geschwind syndrome like hypergraphia and hyposexuality might be pathogenically related to hippocampal atrophy.

The EQ-5D--a generic quality of life measure-is a useful instrument to measure quality of life in patients with Parkinson's disease

OBJECTIVE

To test the feasibility and validity of the EQ-5D (a widely used generic (disease non-specific) quality of life (QoL) instrument which allows comparisons between different patient groups and the general population) to assess QoL in patients with Parkinson's disease.

METHODS

All 124 patients with Parkinson's disease seen in a community based study on the prevalence of parkinsonism were asked to complete a QoL battery comprising the EQ-5D, the medical outcome study short form (SF-36), the PDQ-39, a disease specific instrument to assess QoL in PD, and the Beck depression inventory. A structured questionnaire interview and a complete neurological examination including the Hoehn and Yahr stage of illness scale, the Schwab and England disability scale, the motor section of the unified Parkinson's disease rating scale (UPDRS), and the mini mental state examination (MMSE) were performed on the same day.

RESULTS

The response rate was 78% and the completion rate of the EQ-5D among responders was 96%. The EQ-5D summary index correlated strongly with the PDQ-39 (r=-0.75, p<0.0001) as well as the physical score of the SF-36 (r=0.61, p<0.0001). There was a significant correlation of the EQ-5D summary index with disease severity, as measured by the Hoehn and Yahr stage of illness, the Schwab and England disability scale, the motor section of the UPDRS, and the depression score. The EQ-5D summary index also distinguished between patients with and without depression, falls, postural instability, cognitive impairment hallucinations, and those with deterioration of health over the previous year.

CONCLUSION

The EQ-5D is a feasible and valid instrument to measure QoL in Parkinson's disease and reflects the severity and complications of the disease.

Eliciting EuroQol descriptive data and utility scale values from inpatients. A feasibility study

We conducted a microstudy to elicit health state descriptions and utility values, using the EuroQol instrument, from a sample of acutely ill inpatients on 5 wards at University College London Medical School. Most current work to date has elicited such descriptive and valuation data from random surveys of the general population. One problem with this is that most responders from the general population have not actually experienced the states being valued. Our goal was to ascertain whether there were any differences between the values given by inpatients and those of the general population. However, the small sample size of patients included in our feasibility study means our conclusions must remain tentative. Nevertheless, the results suggest that patients give higher values than the general population. We suggest that more research needs to be done eliciting values from patients.