Effectiveness and cost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilot patient-preference randomised controlled trial

BACKGROUND

Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards.

AIMS

To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP-RCT) design (ISRCTN20804014).

METHOD

We used a PP-RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission.

RESULTS

Forty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (randomised or preference arms), but women who obtained their preferred intervention were more satisfied with treatment.

CONCLUSIONS

Although the sample sizes were too small to allow definite conclusions, the results suggest that when services are able to provide interventions preferred by patients, those patients are more likely to be satisfied with treatment. This pilot study provides some evidence that women's crisis houses are as effective as traditional psychiatric wards, and may be more cost-effective.

Experiences of discrimination among people using mental health services in England 2008-2011

BACKGROUND

Research suggests that levels of discrimination against people using mental health services are high; however, reports of these people's experiences are rare.

AIMS

To determine whether the Time to Change (TTC) programme target of 5% reduction in discrimination has been achieved.

METHOD

Separate samples of people using mental health services were interviewed annually from 2008 to 2011 using the Discrimination and Stigma Scale to record instances of discrimination.

RESULTS

Ninety-one per cent of participants reported one or more experiences of discrimination in 2008 compared with 88% in 2011 (z = -1.9, P = 0.05). The median negative discrimination score was 40% in 2008 and 28% in 2011 (Kruskal-Wallis χ(2) = 83.4, P<0.001).

CONCLUSIONS

The proportion of participants experiencing no discrimination increased significantly over the course of TTC but by less than the initial target. The overall median discrimination score fell by 11.5%. Data from 2010 and 2011 suggest that these gains may be hard to maintain during economic austerity.

Views of the Therapeutic Environment (VOTE): stakeholder involvement in measuring staff perceptions of acute in-patient care

BACKGROUND

The impact of staff perceptions of daily work pressures on burnout requires further exploration because both issues may be adversely affecting the quality of staff interactions with service users.

OBJECTIVES

To use a model of 'stakeholder involvement' to develop and test a self-report instrument capturing nursing staff perceptions of the daily pressures of working in acute in-patient mental health wards.

DESIGN

Measure development followed a participatory methodology, followed by psychometric testing of the new measure of the daily pressures of working on an acute ward (VOTE).

SETTINGS

Acute in-patient wards in an inner London mental health trust.

PARTICIPANTS

All nursing staff from acute in-patient settings are eligible for this study. In total 376 staff (qualified nurses and healthcare assistants) were involved at the various stages of measure development and testing.

METHODS

Focus groups of nursing staff met to discuss their perceptions of acute wards. A twenty item measure was generated through thematic analysis of these data and staff feedback. Reliability and validity were tested and the effects of demographic characteristics on VOTE, and VOTE on burnout were examined.

RESULTS

Staff found VOTE easy to understand and complete. Test-retest reliability and the internal consistency of the measure and subscales were good. A test of criterion validity showed that staff with negative perceptions of the daily pressures of the working on an acute ward also had negative perceptions of job satisfaction and high levels of burnout. Regression modelling showed that VOTE had a significant effect on burnout.

CONCLUSIONS

VOTE is a concise measure which combines aspects of care provision as well as the organisational and professional stressors of acute ward working. VOTE can be used to further explore how staff perceptions of the daily pressures of acute ward working affect the quality of care delivered.

Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study

OBJECTIVE

To investigate the long-term impact of antenatal domestic violence on maternal psychiatric morbidity and child behaviour.

DESIGN

Cohort study.

SETTING

Avon, UK.

POPULATION OR SAMPLE

A birth cohort of 13,617 children and mother dyads were followed to 42 months of age.

METHODS

Experiences of domestic violence and depressive symptoms were gathered at 18 weeks of gestation and up to 33 months after birth, together with maternal, paternal and child characteristics.

MAIN OUTCOME MEASURES

Child behavioural problems were assessed at 42 months using the Revised Rutter Questionnaire.

ANALYSIS

Logistic regression with the use of multiple imputation employing chained equations for missing data.

RESULTS

Antenatal domestic violence was associated with high levels of maternal antenatal (odds ratio [OR], 4.02; 95% confidence interval [CI], 3.4-4.8) and postnatal (OR, 1.29; 95% CI, 1.02-1.63) depressive symptoms after adjustment for potential confounders. Antenatal domestic violence predicted future behavioural problems at 42 months in the child before adjustment for possible confounding and mediating factors (OR, 1.87; 95% CI, 1.45-2.40); this association was not significant after adjustment for high levels of maternal antenatal depressive symptoms, postnatal depressive symptoms or domestic violence since birth.

CONCLUSIONS

Antenatal domestic violence is associated with high levels of both maternal antenatal and postnatal depressive symptoms. It is also associated with postnatal violence, and both are associated with future behavioural problems in the child at 42 months. This is partly mediated by maternal depressive symptoms in the ante- or postnatal period.

Estimating probability of sustained recovery from mild to moderate depression in primary care: evidence from the THREAD study

BACKGROUND

It is important for doctors and patients to know what factors help recovery from depression. Our objectives were to predict the probability of sustained recovery for patients presenting with mild to moderate depression in primary care and to devise a means of estimating this probability on an individual basis.

METHOD

Participants in a randomized controlled trial were identified through general practitioners (GPs) around three academic centres in England. Participants were aged >18 years, with Hamilton Depression Rating Scale (HAMD) scores 12-19 inclusive, and at least one physical symptom on the Bradford Somatic Inventory (BSI). Baseline assessments included demographics, treatment preference, life events and difficulties and health and social care use. The outcome was sustained recovery, defined as HAMD score <8 at both 12 and 26 week follow-up. We produced a predictive model of outcome using logistic regression clustered by GP and created a probability tree to demonstrate estimated probability of recovery at the individual level.

RESULTS

Of 220 participants, 74% provided HAMD scores at 12 and 26 weeks. A total of 39 (24%) achieved sustained recovery, associated with being female, married/cohabiting, having a low BSI score and receiving preferred treatment. A linear predictor gives individual probabilities for sustained recovery given specific characteristics and probability trees illustrate the range of probabilities and their uncertainties for some important combinations of factors.

CONCLUSIONS

Sustained recovery from mild to moderate depression in primary care appears more likely for women, people who are married or cohabiting, have few somatic symptoms and receive their preferred treatment.

Case study evaluating the impact of de-escalation and physical intervention training

Violence and aggression is acknowledged as a serious issue in the mental health services. The aims are to explore whether de-escalation and physical intervention training is effective in reducing incidents and incident severity on a Psychiatric Intensive Care Unit (PICU) and to consider the cost impact. Poisson regression analysis was used to compare the number and severity of incidents on a PICU before and after de-escalation and restraint training. This study shows no significant differences in the number or severity of incidents before and after training. Objective assessment in the evaluation of interventions to improve the safety of the inpatient services is difficult when data is recorded inconsistently or inaccurately. The severity of incidents needs to be defined more fully to allow accurate measurement of the efficiency of techniques employed to resolve violence. The cost impact of training in the management of violence in relation to the benefits remains unclear in the absence of accurate data being recorded.

Interactions of the HIV-1 fusion peptide with large unilamellar vesicles and monolayers. A cryo-TEM and spectroscopic study

We have examined the interaction of the human immunodeficiency virustype 1 fusion peptide (23 amino acid residues) and of a Trp-containing analog with vesicles composed of dioleoylphosphatidylcholine, dioleoylphosphatidylethanolamine and cholesterol (molar ratio, 1:1:1). Both the native and the Trp-substituted peptides bound the vesicles to the same extent and induced intervesicular lipid mixing with comparable efficiency. Infrared reflection-absorption spectroscopy data are compatible with the adoption by the peptide of a main beta-sheet structure in a cospread lipid/peptide monolayer. Cryo-transmission electron microscopy observations of peptide-treated vesicles reveal the existence of a peculiar morphology consisting of membrane tubular elongations protruding from single vesicles. Tryptophan fluorescence quenching by brominated phospholipids and by water-soluble acrylamide further indicated that the peptide penetrated into the acyl chain region closer to the interface rather than into the bilayer core. We conclude that the differential partition and shallow penetration of the fusion peptide into the outer monolayer of a surface-constrained bilayer may account for the detected morphological effects. Such single monolayer-restricted interaction and its structural consequences are compatible with specific predictions of current theories on viral fusion.