revised in amended paper Additional Information about Demographics Unfortunately no additional in... more revised in amended paper Additional Information about Demographics Unfortunately no additional information was collected about individuals that had not attended the programme. We were conscious of the possible reluctanc e of i dividuals to attend for an interview given that they had already declined to participate in the healthy living programme. We aimed to make the qualitative stud y as short in time as possible to encourage participation. We agree additional demographic d ata would have been helpful. It would have been valuable to compare attenders and non attenders in a broad range of demographic indices.
Background Little isknown ofthe epidemiology and care needs of people with adolescent-onsetpsychosis. Aims To examine prevalence and the cross-sectional disability, needs and service provision for adolescent-onset psychosis in areas of central Scotlandwith
Results The 3-year prevalencewas 5.9 per100 000 generalpopulation.Twentyone (20%) adolescentswere... more Results The 3-year prevalencewas 5.9 per100 000 generalpopulation.Twentyone (20%) adolescentswere not in contact withmentalhealth services; 80% of first admissionswere to adult acute psychiatric wards.Those interviewedhad high levels ofmorbidity: 29 (55%) had serious to pervasive impairmentof functioning; therewere relativelyhigh levels of side-effects, negative symptoms, anxiety, occupational, friendship and familydifficulties.Care provisionwas better for‘clinical’than for‘social’domains; 20% had five ormore unmetneeds; 17% had at leastone intractable problem.
BackgroundClinical guidelines for depression in adults recommend the use of outcome measures and ... more BackgroundClinical guidelines for depression in adults recommend the use of outcome measures and stepped care models in routine care. Such measures are based on symptom severity, but response to treatment is likely to also be influenced by personal and contextual factors. This observational study of a routine clinical sample sought to examine the extent to which “symptom severity measures” and “complexity measures” assess different aspects of patient experience, and how they might relate to clinical outcomes, including disengagement from treatment.MethodsSubjects with symptoms of depression (with or without comorbid anxiety) were recruited from people referred to an established Primary Care Mental Health Team using a stepped care model. Each participant completed three baseline symptom measures (the Personal Health Questionnaire (PHQ), Generalised Anxiety Disorder questionnaire (GAD) and Clinical Outcomes in Routine Evaluation (CORE-10)), and two assessments of “case complexity” (th...
During the 1980s and 1990s, Hans J Eysenck conducted a programme of research into the causes, pre... more During the 1980s and 1990s, Hans J Eysenck conducted a programme of research into the causes, prevention and treatment of fatal diseases in collaboration with one of his protégés, Ronald Grossarth-Maticek. This led to what must be the most astonishing series of findings ever published in the peer-reviewed scientific literature with effect sizes that have never otherwise been encounterered in biomedical research. This article outlines just some of these reported findings and signposts readers to extremely serious scientific and ethical criticisms that were published almost three decades ago. Confidential internal documents that have become available as a result of litigation against tobacco companies provide additional insights into this work. It is suggested that this research programme has led to one of the worst scientific scandals of all time. A call is made for a long overdue formal inquiry.
T he last decade has seen a burgeoning interest not only in research in first-episode psychosis (... more T he last decade has seen a burgeoning interest not only in research in first-episode psychosis (FEP), its treatment, and early detection but also in the establishment of several early intervention (EI) services. While the enthusiasm for EI is inherently appealing, it has its detractors. Whether the benefits of a specialized EI approach to treatment of FEP are worth the costs it may incur has generated some heated debate. While we do not have all the answers yet, I will argue that this new development in service delivery is based on good evidence and likely to be cost-beneficial in the long run. To shed more light, rather than simply generate more heat, it is important to examine several key questions related to EI and its benefits. What is EI? Is it effective? Is it worth the cost and should EI be incorporated into mental health policy in Canada? Should EI include services for patients in the so-called prodromal stage of psychosis?
Structured needs assessment as an outcome measure in psychosis: A comparison of two contrasting services
Schizophrenia Research, 1998
Rational policy making for early psychosis might yet become possible
BMJ (Clinical research ed.), 2012
On the basis of the results of previous investigations, Morrison and colleagues estimated that wi... more On the basis of the results of previous investigations, Morrison and colleagues estimated that without active treatment 30% of their study participants with at risk mental states would later develop schizophrenia.1 However, only 9% of control subjects and 7% of those who received cognitive therapy developed a psychotic illness. They have been warned about this lowering of the transition rate for a …
Intensive case management for severe psychotic illness: is there a general benefit for patients with complex needs?
Social Psychiatry and Psychiatric Epidemiology, 2005
The UK700 trial failed to demonstrate an overall benefit of intensive case management (ICM) in pa... more The UK700 trial failed to demonstrate an overall benefit of intensive case management (ICM) in patients with severe psychotic illness. This does not discount a benefit for particular subgroups, and evidence of a benefit of ICM for patients of borderline intelligence has been presented. The aim of this study is to investigate whether this effect is part of a general benefit for patients with severe psychosis complicated by additional needs. In the UK700 trial patients with severe psychosis were randomly allocated to ICM or standard case management. For each patient group with complex needs the effect of ICM is compared with that in the rest of the study cohort. Outcome measures are days spent in psychiatric hospital and the admission and discharge rates. ICM may be of benefit to patients with severe psychosis complicated by borderline intelligence or depression, but may cause patients using illicit drugs to spend more time in hospital. There was no convincing evidence of an effect of ICM in a further seven patient groups. ICM is not of general benefit to patients with severe psychosis complicated by additional needs. The benefit of ICM for patients with borderline intelligence is an isolated effect which should be interpreted cautiously until further data are available.
BackgroundPatients whose symptoms are ‘unexplained by disease’ often have a poor symptomatic outc... more BackgroundPatients whose symptoms are ‘unexplained by disease’ often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.MethodThe Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as ‘not at all’ or only ‘somewhat explained’ by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale (‘much better’ to ‘much worse’) 1 year later.ResultsThe 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI (‘unchanged’, ‘worse’ or ‘much worse’) was reported by 482 (67%) out of ...
Primary Health Care Research & Development, 2010
To describe the service use and clinical outcomes associated with the implementation of a complex... more To describe the service use and clinical outcomes associated with the implementation of a complex intervention designed to improve care for people with depression in a primary care setting. Background: Health systems have limited capacity to provide appropriate psychological and pharmacological treatments for people with depression. Guidance on the treatment of depression in primary care in the United Kingdom was clarified by the National Institute for Clinical Excellence in 2004. However, there is little evidence so far of substantial changes in practice: antidepressant prescriptions continue to rise, there is limited access to psychological therapies and uncertainty persists about who should be treated for what and how. Although the welfare of staff is critical to their therapeutic engagement with patients, this is rarely an explicit focus of health systems design. Method: An observational study examining the implementation of a complex intervention to improve depression care called 'Doing Well', based in 14 general practices in a mixed urban-rural area in Scotland, United Kingdom. A small team of clinicians implemented a programme for people with low mood, depression and adjustment disorder, based on primary care. This programme incorporated a number of changes in standard mental health care, including the following: no 'severity threshold' for referral to secondary care; routine use of an objective measure of depression severity with continuous outcome monitoring; prompt access to guided self-help; prompt 'step-up' care to more formal psychological therapy or medical care, if indicated; and careful attention to staff training and satisfaction. Findings: There was good fidelity to the model of care designed by the programme. There was a high demand for the new service (1.8% of the catchment population each year) but the programme had the capacity to manage this adequately. Clinical outcomes were satisfactory, and antidepressant use adhered to the guidelines.
Which neurological diseases are most likely to be associated with “symptoms unexplained by organic disease”
Journal of Neurology, 2011
Many patients with a diagnosis of neurological disease, such as multiple sclerosis, have symptoms... more Many patients with a diagnosis of neurological disease, such as multiple sclerosis, have symptoms or disability that is considered to be in excess of what would be expected from that disease. We aimed to describe the overall and relative frequency of symptoms 'unexplained by organic disease' in patients attending general neurology clinics with a range of neurological disease diagnoses. Newly referred outpatients attending neurology clinics in all the NHS neurological centres in Scotland, UK were recruited over a period of 15 months. The assessing neurologists recorded their initial neurological diagnoses and also the degree to which they considered the patient's symptoms to be explained by organic disease. Patients completed self report scales for both physical and psychological symptoms. The frequency of symptoms unexplained by organic disease was determined for each category of neurological disease diagnoses. 3,781 patients participated (91% of those eligible). 2,467 patients had a diagnosis of a neurological disease (excluding headache disorders). 293 patients (12%) of these patients were rated as having symptoms only "somewhat" or "not at all" explained by that disease. These patients self-reported more physical and more psychological symptoms than those with more explained symptoms. No category of neurological disease was more likely than the others to be associated with such symptoms although patients with epilepsy had fewer. A substantial proportion of new outpatients with diagnoses of neurological disease also have symptoms regarded by the assessing neurologist as being unexplained by that disease; no single neurological disease category was more likely than others to be associated with this phenomenon.
Psychiatric scandals at home and abroad
Journal of Mental Health, 1993
After the asylums. Community care for people with mental illness. Elaine Murphy. Faber and Faber, London, 1991. no. of pages: 248. Price: �7.99
International Journal of Geriatric Psychiatry, 1993
P02-97 - Implementation of a “stepped care” service for depression service limited rising antidepressant use: a population-based study
European Psychiatry, 2011
IntroductionLike other European countries, the Defined Daily Dose (DDD) of antidepressants prescr... more IntroductionLike other European countries, the Defined Daily Dose (DDD) of antidepressants prescribed in Scotland increased almost fivefold in the fifteen years to 2007/8. The incidence and prevalence of depression has not changed over that period. It is not known whether this rise represents appropriate practice.AimsTo assess the impact of stepped, collaborative care for depression on population antidepressant use.MethodsA new depression service called “Doing Well” was implemented in 15/30 primary care practices in Renfrewshire, Scotland from July 2004 (population 76,013). Prescribing in these practices was compared with the remaining 15 “control” practices in Renfrewshire and with Scotland nationally.Doing Well offered prompt assessment and access to guided self-help or brief CBT or IPT. Antidepressants were not recommended for patients with a PHQ score < 15, though patient preference and clinical judgement were used to guide prescribing decisions.ResultsAntidepressant use foll...
P01-99 - Implementation of a “stepped care” service for depression limited rising antidepressant use: a population-based study
European Psychiatry, 2010
Introduction Like other European countries, the Defined Daily Dose (DDD) of antidepressants presc... more Introduction Like other European countries, the Defined Daily Dose (DDD) of antidepressants prescribed in Scotland increased almost fivefold in the 15y to 2007/8. Aims To assess the impact of stepped, collaborative care for depression on population antidepressant use. Methods A depression service (“Doing Well”) was implemented in 15/30 primary care practices in Renfrewshire, Scotland from July 2004 (population 76,013). Prescribing was compared with the remaining 15 “control” practices in Renfrewshire and Scotland nationally. Doing Well offered prompt assessment and access to guided self-help or brief CBT or IPT. Clinical judgement guided antidepressant recommendations but drugs were not usually recommended for patients with a PHQ score < 15. Results Antidepressant use followed a “rational” profile, increasing with depression severity: PHQ score at referral 0-5 6-10 11-25 16-20 21-27 total antidepressant use 0% 24% 37% 59% 70% 53% [Antidepressant use by depression severity] Antidepressant use increased by 3.8% in Doing Well practices, 11.8% in control practices and 12.9% in Scotland. This represents a relative reduction in DDDs in the intervention area. [Antidepressant use over time by area] Conclusions Providing rapid, local access to brief psychological therapies and rational prescribing support was associated with a relative reduction in the rise of antidepressant use, but a modest increase in prescribing overall.
BackgroundLittle is known of the needs of elderly patients with psychotic illnesses.AimsTo measur... more BackgroundLittle is known of the needs of elderly patients with psychotic illnesses.AimsTo measure the care needs of an epidemiologically based group of patients over the age of 65 years suffering from psychotic illness, using a standardised assessment.MethodAll patients aged 65 years and over with a diagnosis of schizophrenia and related disorders from a defined catchment area were identified. Their health and social care needs were investigated using the Cardinal Needs Schedule.ResultsThe 1-year prevalence of schizophrenia and related disorders was 4.44 per 1000 of the population at risk. There were high levels of unmet need for many patients, including those in National Health Service (NHS) continuing-care beds.ConclusionsMany needs were identified, all of which could be addressed using the existing skills of local health and social care professionals. The investigation raises serious concerns about standards of hospital and community care for elderly patients with schizophrenia....
The concept of early intervention for psychosis has received much attention in recent years. The ... more The concept of early intervention for psychosis has received much attention in recent years. The experience of pioneer services in the USA and Australia has convinced the UK Government to set aside millions of pounds to make dedicated early intervention teams an integral part of standard mental health services across the country. Other governments are set to follow suit. The rationale for early intervention is that there is a higher success rate if psychotic symptoms are treated early than if they are treated after they have been present for some time. It is also claimed that interventions early in the course of the illness can decrease the psychosocial impact of a psychotic illness that leads to secondary disability. But have these assertions been empirically demonstrated? Do such services simply take valuable resources, both in terms of funding and staff, from an already-overstretched mental health system, or do they change the trajectory of the disease process in a fundamental wa...
Objective-To measure needs for care of patients aged 18-65 years with major mental illness. Desig... more Objective-To measure needs for care of patients aged 18-65 years with major mental illness. Design-Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Inter- view of a one in three sample of patients and their main carers with the cardinal needs schedule. Setting-Hamilton, a socially deprived district of Scotland. Subjects-71 subjects were interviewed from the original sample of 263 patients. Main outcome measures-"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requir- ing action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. Results-High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%/6; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investi- gation. Patients not being seen by the community mental health team were similar in severity and levels ofneed to those who were on the community team's caseload. Care was unequivocally and severely inadequate for four patients. Shortcom- ings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. Conclusions-Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of commu- nity care ofpeople with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.
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