1Int J Soc Psychiatry 2000 -1 46: 250-65
PMID11201347
TitleMental health care in Italy: organisational structure, routine clinical activity and costs of a community psychiatric service in Lombardy region.
AbstractThe Magenta Community Mental Health Centre (CMHC) is the public agency responsible for providing adult psychiatric care to about 85,000 adult residents. In 1995, it had 1,145 clients and incurred costs of Euro 1.9 millions. Average cost per patient and per adult resident were Euro 1,661 and Euro 22.2, respectively. These values mask large variation across diagnosis: while patients with schizophrenia and related disorders had an average cost of Euro 3,771, those with neurotic and related disorders had an average cost of Euro 439. Patients with schizophrenia and related disorders (28% of the patients) absorbed about 60% of total costs and made extensive use of several types of services (hospital, outpatient, domiciliary, social and rehabilitative care). Since integrating different types of services is the key element of Italian psychiatric care, the new fee-for-service system adopted by the NHS to fund providers does not appear appropriate, particularly for schizophrenic patients.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
2Int J Soc Psychiatry 2000 -1 46: 250-65
PMID11201347
TitleMental health care in Italy: organisational structure, routine clinical activity and costs of a community psychiatric service in Lombardy region.
AbstractThe Magenta Community Mental Health Centre (CMHC) is the public agency responsible for providing adult psychiatric care to about 85,000 adult residents. In 1995, it had 1,145 clients and incurred costs of Euro 1.9 millions. Average cost per patient and per adult resident were Euro 1,661 and Euro 22.2, respectively. These values mask large variation across diagnosis: while patients with schizophrenia and related disorders had an average cost of Euro 3,771, those with neurotic and related disorders had an average cost of Euro 439. Patients with schizophrenia and related disorders (28% of the patients) absorbed about 60% of total costs and made extensive use of several types of services (hospital, outpatient, domiciliary, social and rehabilitative care). Since integrating different types of services is the key element of Italian psychiatric care, the new fee-for-service system adopted by the NHS to fund providers does not appear appropriate, particularly for schizophrenic patients.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
3Br J Psychiatry 2000 Jul 177: 42-6
PMID10945087
TitleSelf-report quality of life measure for people with schizophrenia: the SQLS.
AbstractQuality of life is the subject of growing interest and investigation.
To develop and validate a short, self-report quality of life questionnaire (the schizophrenia Quality of Life Scale, SQLS).
People with schizophrenia in Liverpool were recruited via the NHS. Items, generated from in-depth interviews, were developed into an 80-item self-report questionnaire. Data were factor analysed, and a shorter form measure was tested for reliability and validity. This measure was administered together with other self-report measures--SF-36, GHQ-12 and HADS--to assess validity.
Data were analysed to produce a final 30-item questionnaire, comprising three scales ('psychosocial', 'motivation and energy', and 'symptoms and side-effects') addressing different SQLS dimensions. Internal consistency reliability of the scale was found to be satisfactory. There was a high level of association with relevant SF-36, GHQ-12 and HADS scores.
The SQLS was completed within 5-10 minutes. It possesses internal reliability and construct validity, and promises to be a useful tool for the evaluation of new treatment regimes for people with schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
4J Clin Nurs 2001 Jan 10: 58-69
PMID11820239
TitleHospital care pathways for patients with schizophrenia.
AbstractGreater emphasis is being placed on reducing clinical variation in managing patient groups in the reformed National Health Service (NHS) in the United Kingdom (UK). The use of a care pathway to enable greater control over the process and quality of care will be explored for patients suffering from schizophrenia. The paper addresses three main factors for the development of care pathways for people suffering from schizophrenia: predictability of the illness; nature of standardized care; and role autonomy. It is argued that the diagnosis of schizophrenia does not lend itself easily to predicting care and treatment within a care pathway framework. However, a care pathway may bring other benefits, such as standardized care and a greater control over the delivery of care. Development and implementation of hospital care pathways require extensiv research. Qualitative research directions are advocated due to the possib difficulties of conducting an experimental study.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
5Br J Med Psychol 2001 Sep 74 Part 3: 277-292
PMID11802842
TitleDifferential psychotic symptomatology in polyglot patients: Case reports and their implications.
AbstractPolyglot psychotic patients can present with either different or less psychotic symptoms depending on the language they use. No known study has used a structured interview to assess such differences. A language history was taken on three patients who were then assessed using the Positive and Negative Syndrome Scale structured interview (SCI-PANSS) for schizophrenia in their two languages. All three patients were found to have different positive symptoms depending on the language used in the interview procedure by the same bilingual researcher. These findings could have important implications in terms of our assessment and treatment of psychotic patients in the NHS. They demonstrate the need to carry out a large study in order to determine how common these findings are in multilingual patients.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
6Br J Med Psychol 2001 Sep 74: 277-92
PMID11589322
TitleDifferential psychotic symptomatology in polyglot patients: case reports and their implications.
AbstractPolyglot psychotic patients can present with either different or less psychotic symptoms depending on the language they use. No known study has used a structured interview to assess such differences. A language history was taken on three patients who were then assessed using the Positive and Negative Syndrome Scale structured interview (SCI-PANSS) for schizophrenia in their two languages. All three patients were found to have different positive symptoms depending on the language used in the interview procedure by the same bilingual researcher. These findings could have important implications in terms of our assessment and treatment of psychotic patients in the NHS. They demonstrate the need to carry out a large study in order to determine how common these findings are in multilingual patients.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
7BMJ 2001 Apr 322: 835-40
PMID11290639
TitleRandomised trial of personalised computer based information for patients with schizophrenia.
AbstractTo compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia.
Randomised trial of three interventions. Modelling of costs of alternatives.
112 patients with schizophrenia in contact with community services; 67 completed the intervention.
Three interventions of five educational sessions: (a) computer intervention combining information from patient's medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) "combination" (first and last sessions with nurse and remainder with computer).
Patients' attendance, opinions, change in knowledge, and psychological state; costs of interventions and patients' use of NHS community services; modelling of costs for these three, and alternative, interventions.
Rates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper.
The computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
8Br J Psychiatry 2003 Mar 182: 241-7
PMID12611788
TitleCare needs of elderly people with schizophrenia. Assessment of an epidemiologically defined cohort in Scotland.
AbstractLittle is known of the needs of elderly patients with psychotic illnesses.
To 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.
All 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.
The 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.
Many 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 findings may be unique, reflecting long-standing problems within a particularly hard-pressed part of the NHS. However, it is not known whether a similar situation exists in other parts of the UK.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
9J Adv Nurs 2003 Feb 41: 295-305
PMID12581117
TitleSupporting carers of people diagnosed with schizophrenia: evaluating change in nursing practice following training.
AbstractUnited Kingdom legislation and clinical standards for schizophrenia challenge nurses to re-examine the support that they provide to carers. Nurses are in a key position to provide this support but may lack the necessary skills to do so. The training programme evaluated in the present study aimed to address this problem.
To evaluate change in clinical practice brought about by post-registration training for mental health nurses in supporting carers of people diagnosed with schizophrenia.
The study was undertaken in collaboration between the Universities of Dundee and Glasgow, and Tayside National Health Service (NHS) Trust (Scotland). Respondents were nine nurses who completed training and then delivered a planned programme of support to carers. Data on nursing practice were gathered through semi-structured interviews with nurses before training and after providing support. Following the support intervention, carers also commented on the nurses' practice.
Eight of the nine nurses reported changes in practice in five key areas: They built collaborative relationships with carers, developed a carer focused approach to their practice, acknowledged and supported the carer role, and made progress in identifying carer needs and accessing resources to meet these needs. Nurses experienced difficulties supporting carers who had mental health problems or previous negative experiences of services. Those who lacked community experience also found it difficult to adjust to working in a community setting. Although clinical supervision helped them to work through these difficulties, they remain largely unresolved.
Findings from this study indicate that appropriate training may enable nurses to improve the support provided to carers of people diagnosed with schizophrenia. This study represents an important stage in determining the nature of support offered to carers by nurses. While developed to help nurses to meet clinical standards set for schizophrenia in the UK, findings may have clinical significance for nurses in other countries.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
10Int J Geriatr Psychiatry 2005 Sep 20: 842-7
PMID16116576
TitlePsychotropic drug use in older people with mental illness with particular reference to antipsychotics: a systematic study of tolerability and use in different diagnostic groups.
AbstractThe objective of the study was to provide observational clinical data on psychotropic drugs used in older people with mental illness.
This was an observational, single-centre, one-week prevalence study of psychiatric symptoms, disorders and psychotropic drug use in older with mental illness cared for by the South West people Yorkshire Mental Health NHS Trust (Wakefield Locality), UK. The clinical assessment included completion of the Psychosis Evaluation Tool for Common use by Caregivers.
A total of 593/660 older patients with mental illness (mean +/- SD age, 76 +/- 8.1 years were assessed. 44.5% had dementia (excluding vascular dementia) and 33.7% had a mood disorder. Of the total, 20.4% did not receive CNS active medication. Of those receiving CNS active medication approximately half (51.3%) took antipsychotics and 46.2% antidepressants. Of 304 patients taking antipsychotics, 87% took only one medication. However, patients with schizophrenia and related disorders were significantly more likely to be prescribed two or more antipsychotics (p < 0.001). Risperidone was the most frequently prescribed antipsychotic (n = 136, 44.7%). Risperidone doses were significantly lower for patients with dementia and mood disorders than with schizophrenia (p < 0.002). Side-effects from antipsychotics were significantly greater in patients with schizophrenia, suggesting a dose-related effect. Risperidone appeared to be well tolerated in all patients with no evidence of cerebrovascular side-effects in patients taking it.
Psychotropic drugs were commonly used by older people in contact with mental health services. The doses of antipsychotics used in dementia and affective disorders were significantly lower than in schizophrenia. Risperidone was the most commonly used drug in all diagnostic groups including dementia. Despite a relatively large numbers of patients receiving risperidone in this naturalistic study, no serious side-effects were reported or identified. In this paper we focus our findings on antipsychotics in the light of recent advice from the Committee on Safety of Medicines (UK).
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
11Clin Drug Investig 2006 -1 26: 447-57
PMID17163277
TitleCost-effectiveness analysis of schizophrenia relapse prevention : an economic evaluation of the ZEUS (Ziprasidone-Extended-Use-In-Schizophrenia) study in Spain.
AbstractThe aim of this study was to estimate the cost-effectiveness of schizophrenia relapse prevention in Spain using data from the ZEUS (Ziprasidone-Extended-Use-in-schizophrenia) study.
Treatment of schizophrenia was modeled over 1 year using a retrospective deterministic model from the Spanish National Health System (NHS) perspective (year 2005). The primary outcome was the probability of relapse occurring within a 52-week period of treatment with daily doses of ziprasidone 40-160mg versus placebo. Data were obtained from a randomised, double-blind clinical trial (n = 218 patients). Antipsychotic cost, concomitant medications to treat adverse events (for example extrapyramidal symptoms) and medical costs associated with adverse events were derived from the clinical trial results and a Spanish health cost database. The average cost of a relapse admitted to hospital in Spain (3421 euro) was obtained from a retrospective study.
The probability of psychosis relapse was 0.77 with placebo, and 0.43, 0.35, 0.36 and 0.38 with ziprasidone daily doses of 40, 80, 160mg and average dose, respectively (p < 0.01 vs placebo in all cases). The average annual incremental cost per relapse avoided was 186 euro for the average dose, ranging from a saving of 557 euro (80 mg/day) to an incremental cost of 1015 euro (160 mg/day), and was lower in all cases than the minimum cost of a relapse (2830 euro).
According to this evaluation, psychosis relapse prevention with ziprasidone is cost effective compared with no treatment from the Spanish NHS perspective. Ziprasidone therapy avoids a considerable number of relapses at a reasonable cost, producing cost savings.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
12Schizophr Bull 2006 Oct 32: 715-23
PMID16540702
TitleRandomized controlled trial of effect of prescription of clozapine versus other second-generation antipsychotic drugs in resistant schizophrenia.
AbstractThere is good evidence that clozapine is more efficacious than first-generation antipsychotic drugs in resistant schizophrenia. It is less clear if clozapine is more effective than the other second-generation antipsychotic (SGA) drugs. A noncommercially funded, pragmatic, open, multisite, randomized controlled trial was conducted in the United Kingdom National Health Service (NHS). Participants were 136 people aged 18-65 with DSM-IV schizophrenia and related disorders whose medication was being changed because of poor clinical response to 2 or more previous antipsychotic drugs. Participants were randomly allocated to clozapine or to one of the class of other SGA drugs (risperidone, olanzapine, quetiapine, amisulpride) as selected by the managing clinician. Outcomes were assessed blind to treatment allocation. One-year assessments were carried out in 87% of the sample. The intent to treat comparison showed no statistically significant advantage for commencing clozapine in Quality of Life score (3.63 points; CI: 0.46-7.71; p = .08) but did show an advantage in Positive and Negative Syndrome Scale (PANSS) total score that was statistically significant (-4.93 points; CI: -8.82 to -1.05; p = .013) during follow-up. Clozapine showed a trend toward having fewer total extrapyramidal side effects. At 12 weeks participants who were receiving clozapine reported that their mental health was significantly better compared with those receiving other SGA drugs. In conclusion, in people with schizophrenia with poor treatment response to 2 or more antipsychotic drugs, there is an advantage to commencing clozapine rather than other SGA drugs in terms of symptom improvement over 1 year.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
13J Clin Psychiatry 2007 Jul 68: 1027-30
PMID17685738
TitleOutcome following clozapine discontinuation: a retrospective analysis.
AbstractClozapine is uniquely effective in refractory schizophrenia, but treatment attrition is high. There has been minimal formal study of the outcomes of stopping clozapine, beyond published observations of the time period immediately after cessation. Our aim was to establish medium-term outcome in patients stopping clozapine in normal clinical practice.
This study was a retrospective analysis of all subjects registered with Clozaril Patient Monitoring Service and treated in South London and Maudsley National Health Service (NHS) Trust who stopped clozapine between March 2002 and March 2005 after at least 1 year's treatment. Case note review was performed to determine relevant information for 1 year before and 1 year after discontinuation of clozapine, including subject details, reasons for stopping, and clinical outcome 1 year after discontinuation. The primary outcome measure was the Global Assessment of Functioning scale.
Thirty-five patients met inclusion criteria. Twelve had died while receiving clozapine. Of those followed up for 1 year after cessation (N = 23), mean Global Assessment of Functioning scores fell by 15 points (95% CI = 6.6 to 24.3; p = .002). Days spent in hospital rose from a mean of 74.1 (SD = 137.3) to 119.8 (SD = 143.5) (p = .214).
Discontinuation of clozapine has a marked negative impact on clinical status. Death is a common cause of clozapine cessation.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
14Implement Sci 2007 -1 2: 8
PMID17386102
TitleDifficulties implementing a mental health guideline: an exploratory investigation using psychological theory.
AbstractEvaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. While implementation depends on clinicians and managers changing a variety of behaviours, psychological theories of behaviour and behaviour change are seldom used to try to understand difficulties in implementation or to develop interventions to overcome them.
This study applied psychological theory to examine explanations for difficulties in implementation. It used a theoretical framework derived from an interdisciplinary consensus exercise to code interviews across 11 theoretical domains. The focus of the study was a National Institute for Health and Clinical Excellence's schizophrenia guideline recommendation that family intervention should be offered to the families of people with schizophrenia.
Participants were recruited from community mental health teams from three United Kingdom National Health Service (NHS) Trusts; 20 members (social workers, nurses, team managers, psychologists, and psychiatrists) participated. Semi-structured interviews were audio-taped and transcribed. Interview questions were based on the theoretical domains and addressed respondents' knowledge, attitudes and opinions regarding the guideline. Two researchers independently coded the transcript segments from each interview that were related to each theoretical domain. A score of 1 indicated that the transcript segments relating to the domain did not appear to contain description of difficulties in implementation of the family therapy guidelines; similarly a score of 0.5 indicated possible difficulties and a score of 0 indicated definite difficulties.
Coding respondents' answers to questions related to the three domains 'beliefs about consequences,' 'social/professional role and identity,' and 'motivation' produced the three highest total scores indicating that factors relating to these domains were unlikely to constitute difficulties in implementation. 'Environmental context and resources' was the lowest scoring domain, with 'Emotion' scoring the second lowest, suggesting that these were likely to be areas for considering intervention. The two main resources identified as problems were time and training. The emotions that appeared to potentially influence the offer of family therapy were self-doubt and fear.
This exploratory study demonstrates an approach to developing a theoretical understanding of implementation difficulties.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
15Health Technol Assess 2008 May 12: iii-iv, ix-163
PMID18462577
TitleStructural neuroimaging in psychosis: a systematic review and economic evaluation.
AbstractTo establish the clinical effectiveness and cost-effectiveness of structural neuroimaging [structural magnetic resonance imaging (MRI) or computed tomography (CT) scanning] for all patients with psychosis, particularly a first episode of psychosis, relative to the current UK practice of selective screening only where it is clinically indicated.
Major electronic databases were searched from inception to November 2006.
A systematic review of studies reporting the additional diagnostic benefit of structural MRI, CT or combinations of these in patients with psychosis was conducted. The economic assessment consisted of a systematic review of economic evaluations and the development of a threshold analysis to predict the gain in quality-adjusted life-years (QALYs) required to make neuroimaging cost-effective at commonly accepted threshold levels (20,000 pounds and 30,000 pounds per QALY). Sensitivity analyses of several parameters including prevalence of psychosis were performed.
The systematic review included 24 studies of a diagnostic before-after type of design evaluating the clinical benefit of CT, structural MRI or combinations in treatment-naive, first-episode or unspecified psychotic patients, including one in schizophrenia patients resistant to treatment. Also included was a review of published case reports of misidentification syndromes. Almost all evidence was in patients aged less than 65 years. In most studies, structural neuroimaging identified very little that would influence patient management that was not suspected based on a medical history and/or physical examination and there were more incidental findings. In the four MRI studies, approximately 5% of patients had findings that would influence clinical management, whereas in the CT studies, approximately 0.5% of patients had these findings. The review of misidentification syndromes found that 25% of CT scans affected clinical management, but this may have been a selected and therefore unrepresentative sample. A threshold analysis with a 1-year time horizon was undertaken. This combined the incremental cost of routine scanning with a threshold cost per QALY value of 20,000 pounds and 30,000 pounds to predict the QoL gain required to meet these threshold values. Routine scanning versus selective scanning appears to produce different results for MRI and CT. With MRI scanning the incremental cost is positive, ranging from 37 pounds to 150 pounds; however, when scanning routinely using CT, the result is cost saving, ranging from 7 pounds to 108 pounds with the assumption of a 1% prevalence rate of tumours/cysts or other organic causes amenable to treatment. This means that for the intervention to be viewed as cost-effective, the QALY gain necessary for MRI scanning is 0.002-0.007 and with CT scanning the QALY loss that can be tolerated is between 0.0003 and 0.0054 using a 20,000 pounds threshold value. These estimates were subjected to sensitivity analysis. With a 3-month time delay, MRI remains cost-incurring with a small gain in QoL required for the intervention to be cost-effective; routine scanning with CT remains cost-saving. When the sensitivity of CT is varied to 50%, routine scanning is both cost-incurring or cost-saving depending on the scenario. Finally, the results have been shown to be sensitive to the assumed prevalence rate of brain tumours in a psychotic population.
The evidence to date suggests that if screening with structural neuroimaging was implemented in all patients presenting with psychotic symptoms, little would be found to affect clinical management in addition to that suspected by a full clinical history and neurological examination. From an economic perspective, the outcome is not clear. The strategy of neuroimaging for all is either cost-incurring or cost-saving (dependent upon whether MRI or CT is used) if the prevalence of organic causes is around 1%. However, these values are nested within a number of assumptions, and so have to be interpreted with caution. The main research priorities are to monitor the current use of structural neuroimaging in psychosis in the NHS to identify clinical triggers to its current use and subsequent outcomes; to undertake well-conducted diagnostic before-and-after studies on representative populations to determine the clinical utility of structural neuroimaging in this patient group, and to determine whether the most appropriate structural imaging modality in psychosis should be CT or MRI.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
16J. Psychopharmacol. (Oxford) 2008 Mar 22: 128-31
PMID18308820
TitleImpact of risperidone long acting injection on resource utilization in psychiatric secondary care.
AbstractRisperidone long acting injection (RLAI) is the only long acting atypical antipsychotic available in the UK. Its impact on NHS resource use has not been widely studied. This review of medical records was conducted to quantify the impact of RLAI on NHS psychiatric secondary care resource use, primarily in terms of episodes of inpatient hospital care 12 months before and 12 months after RLAI initiation. Data on number of hospitalizations and hospital bed days were collected retrospectively, from patient notes and hospital databases in four acute psychiatric units in the UK for all individuals with a diagnosis of schizophrenia or schizoaffective disorder who were prescribed RLAI more than 12 months previously. Data were collected on 100 individuals (58 male) with a mean age 40.8 years (range 19-70). The median duration of illness before RLAI initiation was 12 years (range six months to 43 years). There were 62 admissions in the 12 months pre-RLAI, falling to 22 admissions in the 12 months post-RLAI. Number of admissions, we argue, offer a more reliable indicator of the impact of treatment than total hospital bed days in this type of study. In this study there were 40 fewer admissions in the 12 months after RLAI was initiated compared with the previous 12 months. This is important as readmission is a good proxy measure of relapse, and adherence to medication is known to be a key factor in relapse prevention.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
17BMJ 2008 -1 337: a1837
PMID18845592
TitleRetrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006.
AbstractTo analyse the number of voluntary and involuntary (detentions under the Mental Health Act 1983) admissions for mental disorders between 1996 and 2006 in England.
Retrospective analysis.
England.
Number of voluntary and involuntary admissions for mental disorders in England's health service, number of involuntary admissions to private beds, and number of NHS beds for patients with mental disorders or learning disabilities.
Admissions for mental disorders in the NHS in England peaked in 1998 and then started to fall. Reductions in admissions were confined to patients with depression, learning disabilities, or dementia. Admissions for schizophrenic and manic disorders did not change whereas those for drug and alcohol problems increased. The number of NHS psychiatric beds decreased by 29%. The total number of involuntary admissions per annum increased by 20%, with a threefold increase in the likelihood of admission to a private facility. Patients admitted involuntarily occupied 23% of NHS psychiatric beds in 1996 but 36% in 2006.
Psychiatric inpatient care changed considerably in the decade from 1996 to 2006, with more involuntary admissions to fewer NHS beds. The case mix has shifted further towards psychotic and substance misuse disorders, which has changed the milieu of inpatient wards. Increasing proportions of involuntary patients were admitted to private facilities.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
18BMC Psychiatry 2009 -1 9: 51
PMID19674459
TitleThe South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data.
AbstractCase registers have been used extensively in mental health research. Recent developments in electronic medical records, and in computer software to search and analyse these in anonymised format, have the potential to revolutionise this research tool.
We describe the development of the South London and Maudsley NHS Foundation Trust (SLAM) Biomedical Research Centre (BRC) Case Register Interactive Search tool (CRIS) which allows research-accessible datasets to be derived from SLAM, the largest provider of secondary mental healthcare in Europe. All clinical data, including free text, are available for analysis in the form of anonymised datasets. Development involved both the building of the system and setting in place the necessary security (with both functional and procedural elements).
Descriptive data are presented for the Register database as of October 2008. The database at that point included 122,440 cases, 35,396 of whom were receiving active case management under the Care Programme Approach. In terms of gender and ethnicity, the database was reasonably representative of the source population. The most common assigned primary diagnoses were within the ICD mood disorders (n = 12,756) category followed by schizophrenia and related disorders (8158), substance misuse (7749), neuroses (7105) and organic disorders (6414).
The SLAM BRC Case Register represents a 'new generation' of this research design, built on a long-running system of fully electronic clinical records and allowing in-depth secondary analysis of both numerical, string and free text data, whilst preserving anonymity through technical and procedural safeguards.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
19Int J Nurs Stud 2009 Dec 46: 1604-23
PMID19481205
TitleThe effectiveness and active ingredients of mutual support groups for family caregivers of people with psychotic disorders: a literature review.
AbstractTo explore the literature through a systematic search to assess the effectiveness of mutual support groups for family caregivers of people with schizophrenia and other psychotic disorders.
This review of the research literature was based on the procedures suggested by the National Health Service Centre for Reviews and Dissemination (2001) Report Number 4 in the UK [National Health Service Centre for Reviews and Dissemination, 2001. Undertaking Systematic Reviews of Research on Effectiveness: CRD's Guidance for those Carrying out or Commissioning Reviews (CRD Report Number 4). 2nd ed., University of York, York, UK]. A combined free-text and thesaurus approach was used to search relevant research studies within electronic databases, including Medline, Embase, CINAHL, OVID full-text, PsycINFO, the Cochrane Library, the British Nursing Index, the NHS National Research register, and System for Info on Grey literature for the period 1980-2007. Reference lists of all retrieved literature were also searched to identify studies that may have been missed. Twenty-five research studies were selected for inclusion in the analysis on the basis that they were either family led or professional-facilitated support group programmes for family caregivers of people with schizophrenia or other psychotic disorders.
The review identified that most studies on this group programme used qualitative, exploratory cross-sectional surveys and quasi-experimental study designs (n=19); six were experimental studies or randomised controlled trials. There were only a few small-scale, single-centre controlled trials with the findings supporting the significant positive effects of mutual support groups on families' and patients' psychosocial well-being. A number of non-experimental studies conducted in Western countries reported benefits of group participation up to 1 year, such as increased knowledge about the illness, reduced burden and distress, and enhanced coping ability and social support. However, many of these studies lacked rigorous control and did not use standardised and valid instruments as outcome measures or schedule follow-up to examine the long-term effects of support groups on families and/or patients.
With increasing recognition of benefits from mutual support, this review highlights the dearth of evidence for the effects and active ingredients of mutual support groups. Mutual support may have significant impacts on long-term psychosocial and nursing interventions for both patients with severe mental illness and their families in community mental health care. Further research is recommended to investigate the therapeutic components and effects of mutual support groups for family caregivers of people with schizophrenia and psychotic disorders across cultures.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
20Eur Arch Psychiatry Clin Neurosci 2009 Jun 259: 239-47
PMID19267255
TitleUK cost-consequence analysis of aripiprazole in schizophrenia: diabetes and coronary heart disease risk projections (STAR study).
AbstractPatients with schizophrenia experience elevated rates of morbidity and mortality, largely due to an increased incidence of cardiovascular disease and diabetes. There is increasing concern that some atypical antipsychotic therapies are associated with adverse metabolic symptoms, such as weight gain, dyslipidaemia and glucose dysregulation. These metabolic symptoms may further increase the risk of coronary heart disease (CHD) and diabetes in this population and, subsequently, the cost of treating these patients' physical health. The STAR study showed that the metabolic side effects of aripiprazole treatment are less than that experienced by those receiving standard-of-care (SOC). In a follow-up study the projected risks for diabetes or CHD, calculated using the Stern and Framingham models, were lower in the aripiprazole treatment group. Assuming the risk of diabetes onset/CHD events remained linear over 10 years, these risks were used to estimate the difference in direct and indirect cost consequences of diabetes and CHD in schizophrenia patients treated with aripiprazole or SOC over a 10-year period. Diabetes costs were estimated from the UKPDS and UK T(2)ARDIS studies, respectively, and CHD costs were estimated using prevalence data from the Health Survey of England and the published literature. All costs were inflated to 2007 costs using the NHS pay and prices index. The number of avoided diabetes cases (23.4 cases per 1,000 treated patients) in patients treated with aripiprazole compared with SOC was associated with estimated total (direct and indirect) cost savings of 37,261,293 pounds over 10 years for the UK population. Similarly, the number of avoided CHD events (3.7 events per 1,000 treated patients) was associated with estimated total cost savings of 7,506,770 pounds over 10 years. Compared with SOC, aripiprazole treatment may provide reductions in the health and economic burden to schizophrenia patients and health care services in the UK as a result of its favourable metabolic profile.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
21J Clin Nurs 2009 Feb 18: 591-600
PMID19192006
TitleHIV prevention for people with serious mental illness: a survey of mental health workers' attitudes, knowledge and practice.
AbstractThe aim of this survey was to investigate the attitudes, knowledge and reported practice (capabilities) of mental health workers concerning human immunodeficiency virus (HIV) and other sexually transmitted diseases in people with serious mental illness.
People with serious mental illness are at increased risk of HIV and other sexually transmitted infections. Mental health workers have a key role to play in promoting sexual health in this population, but it is unclear how they perceive their role in this work and whether they have the capabilities to deliver sexual health promotion.
Cross sectional survey.
A questionnaire was devised and distributed to 650 mental health workers working in a London (UK) NHS mental health service.
A response rate of 44% was achieved. Overall, workers reported positive attitudes to sexual health promotion and were knowledgeable about risk behaviours and risk factors for HIV infection. Adherence to glove wearing was good. However, participants' knowledge about HIV/AIDS in people with schizophrenia was poor and most reported they were not engaged in sexual health promotion activities with people with serious mental illness. Glove wearing was predicted by those who had drug and alcohol training and clinical experience and knowledge of risk factors was predicted by previous health promotion training. No other demographic factors predicted any of the other subscales.
Mental health workers require training to provide skills for health promotion regarding sexual health and HIV in people with serious mental health problems. In addition, there needs to be more research on risk behaviours.
The development of effective interventions to reduce this behaviour.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
22Psychiatr Serv 2009 Feb 60: 240-5
PMID19176419
TitleUsing patient-reported outcomes in schizophrenia: the Scottish Schizophrenia Outcomes Study.
AbstractThe primary aim of the Scottish schizophrenia Outcomes Study (SSOS) was to assess the feasibility and utility of routinely collecting outcome data in everyday clinical settings. Data were collected over three years in the Scottish National Health Service (NHS). There were two secondary aims of SSOS: first, to compare data from patient-rated, objective, and clinician-rated outcomes, and second, to describe trends in outcome data and service use across Scotland over the three years of the study (2002-2005).
This study used a naturalistic, longitudinal, observational cohort design. A representative sample of 1,015 persons with ICD-10 F20-F29 diagnoses (schizophrenia, schizotypal disorders, or delusional disorders) was assessed annually using the clinician-rated measure, the Health of the Nation Outcome Scale (HoNOS), and the patient-reported assessment, the Avon Mental Health Measure (Avon). Objective outcomes data and information on services and interventions were collected. Data were analyzed with regression modeling.
Of the 1,015 persons recruited, 78% of the cohort (N=789) completed the study. Over the study period, significant decreases were seen in the number of hospitalizations, incidence of attempted suicide and self-harm, and civil detentions. Avon scores indicated significant improvement on all subscales (behavior, social, access, and mental health) and on the total score. However, HoNOS scores on the behavior and symptom subscales did not change, scores on the impairment subscale increased significantly (indicating increased levels of impairment), and scores on the social subscale decreased significantly (indicating improved social functioning).
This study has demonstrated that it is feasible within the Scottish NHS to routinely collect meaningful outcomes data in schizophrenia. Patient-reported assessments were also successfully collected and used in care plans. This model shows that it is possible to incorporate patient-reported assessments into routine care for schizophrenia. Such assessments may provide useful data for clinicians and may improve treatment adherence. The pattern of outcomes and interventions confirms that despite the introduction of guidelines, new treatments, and new services, people with schizophrenia continue to have high levels of chronic disability.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
23Psychiatr Serv 2009 Feb 60: 240-5
PMID19176419
TitleUsing patient-reported outcomes in schizophrenia: the Scottish Schizophrenia Outcomes Study.
AbstractThe primary aim of the Scottish schizophrenia Outcomes Study (SSOS) was to assess the feasibility and utility of routinely collecting outcome data in everyday clinical settings. Data were collected over three years in the Scottish National Health Service (NHS). There were two secondary aims of SSOS: first, to compare data from patient-rated, objective, and clinician-rated outcomes, and second, to describe trends in outcome data and service use across Scotland over the three years of the study (2002-2005).
This study used a naturalistic, longitudinal, observational cohort design. A representative sample of 1,015 persons with ICD-10 F20-F29 diagnoses (schizophrenia, schizotypal disorders, or delusional disorders) was assessed annually using the clinician-rated measure, the Health of the Nation Outcome Scale (HoNOS), and the patient-reported assessment, the Avon Mental Health Measure (Avon). Objective outcomes data and information on services and interventions were collected. Data were analyzed with regression modeling.
Of the 1,015 persons recruited, 78% of the cohort (N=789) completed the study. Over the study period, significant decreases were seen in the number of hospitalizations, incidence of attempted suicide and self-harm, and civil detentions. Avon scores indicated significant improvement on all subscales (behavior, social, access, and mental health) and on the total score. However, HoNOS scores on the behavior and symptom subscales did not change, scores on the impairment subscale increased significantly (indicating increased levels of impairment), and scores on the social subscale decreased significantly (indicating improved social functioning).
This study has demonstrated that it is feasible within the Scottish NHS to routinely collect meaningful outcomes data in schizophrenia. Patient-reported assessments were also successfully collected and used in care plans. This model shows that it is possible to incorporate patient-reported assessments into routine care for schizophrenia. Such assessments may provide useful data for clinicians and may improve treatment adherence. The pattern of outcomes and interventions confirms that despite the introduction of guidelines, new treatments, and new services, people with schizophrenia continue to have high levels of chronic disability.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
24Psychol Med 2009 Jun 39: 967-76
PMID19091161
TitleA study of psychiatrists' concepts of mental illness.
AbstractThere are multiple models of mental illness that inform professional and lay understanding. Few studies have formally investigated psychiatrists' attitudes. We aimed to measure how a group of trainee psychiatrists understand familiar mental illnesses in terms of propositions drawn from different models.
We used a questionnaire study of a sample of trainees from South London and Maudsley National Health Service (NHS) Foundation Trust designed to assess attitudes across eight models of mental illness (e.g. biological, psychodynamic) and four psychiatric disorders. Methods for analysing repeated measures and a principal components analysis (PCA) were used.
No one model was endorsed by all respondents. Model endorsement varied with disorder. Attitudes to schizophrenia were expressed with the greatest conviction across models. Overall, the 'biological' model was the most strongly endorsed. The first three components of the PCA (interpreted as dimensions around which psychiatrists, as a group, understand mental illness) accounted for 56% of the variance. Each main component was classified in terms of its distinctive combination of statements from different models: PC1 33% biological versus non-biological; PC2 12% 'eclectic' (combining biological, behavioural, cognitive and spiritual models); and PC3 10% psychodynamic versus sociological.
Trainee psychiatrists are most committed to the biological model for schizophrenia, but in general are not exclusively committed to any one model. As a group, they organize their attitudes towards mental illness in terms of a biological/non-biological contrast, an 'eclectic' view and a psychodynamic/sociological contrast. Better understanding of how professional group membership influences attitudes may facilitate better multidisciplinary working.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
25Health Technol Assess 2010 Jan 14: 1-157, iii
PMID20031087
TitleThe clinical effectiveness and cost-effectiveness of testing for cytochrome P450 polymorphisms in patients with schizophrenia treated with antipsychotics: a systematic review and economic evaluation.
AbstractTo determine whether testing for cytochrome P450 (CYP) polymorphisms in adults entering antipsychotic treatment for schizophrenia leads to improvement in outcomes, is useful in medical, personal or public health decision-making, and is a cost-effective use of health-care resources.
The following electronic databases were searched for relevant published literature: Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Technology Assessment database, ISI Web of Knowledge, MEDLINE, PsycINFO, NHS Economic Evaluation Database, Health Economic Evaluation Database, Cost-effectiveness Analysis (CEA) Registry and the Centre for Health Economics website. In addition, publicly available information on various genotyping tests was sought from the internet and advisory panel members.
A systematic review of analytical validity, clinical validity and clinical utility of CYP testing was undertaken. Data were extracted into structured tables and narratively discussed, and meta-analysis was undertaken when possible. A review of economic evaluations of CYP testing in psychiatry and a review of economic models related to schizophrenia were also carried out.
For analytical validity, 46 studies of a range of different genotyping tests for 11 different CYP polymorphisms (most commonly CYP2D6) were included. Sensitivity and specificity were high (99-100%). For clinical validity, 51 studies were found. In patients tested for CYP2D6, an association between genotype and tardive dyskinesia (including Abnormal Involuntary Movement Scale scores) was found. The only other significant finding linked the CYP2D6 genotype to parkinsonism. One small unpublished study met the inclusion criteria for clinical utility. One economic evaluation assessing the costs and benefits of CYP testing for prescribing antidepressants and 28 economic models of schizophrenia were identified; none was suitable for developing a model to examine the cost-effectiveness of CYP testing.
Tests for determining genotypes appear to be accurate although not all aspects of analytical validity were reported. Given the absence of convincing evidence from clinical validity studies, the lack of clinical utility and economic studies, and the unsuitability of published schizophrenia models, no model was developed; instead key features and data requirements for economic modelling are presented. Recommendations for future research cover both aspects of research quality and data that will be required to inform the development of future economic models.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
26BMC Psychiatry 2010 -1 10: 77
PMID20920287
TitleAll-cause mortality among people with serious mental illness (SMI), substance use disorders, and depressive disorders in southeast London: a cohort study.
AbstractHigher mortality has been found for people with serious mental illness (SMI, including schizophrenia, schizoaffective disorders, and bipolar affective disorder) at all age groups. Our aim was to characterize vulnerable groups for excess mortality among people with SMI, substance use disorders, depressive episode, and recurrent depressive disorder.
A case register was developed at the South London and Maudsley National Health Services Foundation Trust (NHS SLAM), accessing full electronic clinical records on over 150,000 mental health service users as a well-defined cohort since 2006. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information since 2008. Deaths were identified by regular national tracing returns after 2006. Standardized mortality ratios (SMRs) were calculated for the period 2007 to 2009 using SLAM records for this period and the expected number of deaths from age-specific mortality statistics for the England and Wales population in 2008. Data were stratified by gender, ethnicity, and specific mental disorders.
A total of 31,719 cases, aged 15 years old or more, active between 2007-2009 and with mental disorders of interest prior to 2009 were detected in the SLAM case register. SMRs were 2.15 (95% CI: 1.95-2.36) for all SMI with genders combined, 1.89 (1.64-2.17) for women and 2.47 (2.17-2.80) for men. In addition, highest mortality risk was found for substance use disorders (SMR = 4.17; 95% CI: 3.75-4.64). Age- and gender-standardised mortality ratios by ethnic group revealed huge fluctuations, and SMRs for all disorders diminished in strength with age. The main limitation was the setting of secondary mental health care provider in SLAM.
Substantially higher mortality persists in people with serious mental illness, substance use disorders and depressive disorders. Furthermore, mortality risk differs substantially with age, diagnosis, gender and ethnicity. Further research into specific risk groups is required.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
27Trials 2011 -1 12: 167
PMID21726440
TitleThe serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial.
AbstractThe serious mental illness Health Improvement Profile [HIP] is a brief pragmatic tool, which enables mental health nurses to work together with patients to screen physical health and take evidence-based action when variables are identified to be at risk. Piloting has demonstrated clinical utility and acceptability.
A single blind parallel group cluster randomised controlled trial with secondary economic analysis and process observation. Unit of randomisation: mental health nurses [MHNs] working in adult community mental health teams across two NHS Trusts.
Patients over 18 years with a diagnosis of schizophrenia, schizoaffective or bipolar disorder on the caseload of participating MHNs.
To determine the effects of the HIP programme on patients' physical wellbeing assessed by the physical component score of the Medical Outcome Study (MOS) 36 Item Short Form Health Survey version 2 [SF-36v2].
To determine the effects of the HIP programme on: cost effectiveness, mental wellbeing, cardiovascular risk, physical health care attitudes and knowledge of MHNs and to determine the acceptability of the HIP Programme in the NHS. Consented nurses (and patients) will be randomised to receive the HIP Programme or treatment as usual. Outcomes will be measured at baseline and 12 months with a process observation after 12 months to include evaluation of patients' and professionals' experience and observation of any effect on care plans and primary-secondary care interface communication. Outcomes will be analysed on an intention-to-treat (ITT) basis.
The results of the trial and process observation will provide information about the effectiveness of the HIP Programme in supporting MHNs to address physical comorbidity in serious mental illness. Given the current unacceptable prevalence of physical comorbidity and mortality in the serious mental illness population, it is hoped the HIP trial will provide a timely contribution to evidence on organisation and delivery of care for patients, clinicians and policy makers.

ISRCTN41137900.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
28Int Rev Psychiatry 2011 -1 23: 55-60
PMID21338299
TitleThe economic cost of pathways to care in first episode psychosis.
AbstractFew studies have examined the economic cost of psychoses other than schizophrenia and there have been no studies of the economic cost of pathways to care in patients with their first episode of psychosis. The aims of this study were to explore the economic cost of pathways to care in patients with a first episode of psychosis and to examine variation in costs. Data on pathways to care for first episode psychosis patients referred to specialist mental health services in south-east London and Nottingham between 1997-2000. Costs of pathway events were estimated and compared between diagnostic groups. The average costs for patients in south-east London were £54 (CI £33-£75) higher, compared to patients in Nottingham. Across both centres unemployed patients had £25 (CI £7-£43) higher average costs compared to employed patients. Higher costs were associated with being unemployed and living in south-east London and these differences could not be accounted for by any single factor. This should be considered when the National Health Service (NHS) is making decisions about funding.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
29Ther Adv Psychopharmacol 2011 Feb 1: 19-23
PMID23983923
TitleMelperone in treatment-refractory schizophrenia: a case series.
AbstractClozapine is the treatment of choice in refractory schizophrenia, but a substantial proportion of patients experience inadequate response or tolerate the drug poorly. Melperone has been suggested as a possible alternative in such patients. This case series examines the efficacy of melperone in refractory schizophrenia.
All patients prescribed melperone at the South London and Maudsley NHS Foundation Trust were identified using a pharmacy database. The main outcome was to determine the proportion of patients discharged on melperone.
Three of 21 patients were discharged on melperone. The primary reason for discontinuation was lack of efficacy.
Melperone may be an option in a very few patients with refractory schizophrenia, but it should not be considered as an alternative to clozapine.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
30PLoS ONE 2011 -1 6: e19590
PMID21611123
TitleLife expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London.
AbstractDespite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth.
People who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007-09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007-09, using a life table method.
A total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007-09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost).
The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
31J Ment Health 2011 Aug 20: 328-35
PMID21332321
TitleProvision and practice of art therapy for people with schizophrenia: results of a national survey.
AbstractArt therapy has been recommended as a treatment for people with psychosis. However, little is known about the availability, organisation or delivery of art therapy within NHS settings.
To describe the availability, structure and content of art therapy for people with schizophrenia provided by NHS services in England.
A survey of art therapists working in a randomly selected sample of half of all mental health Trusts in England.
Not all mental health Trusts employ art therapists. Those which do employ few therapists, typically on a sessional basis who work across a variety of inpatient and community-based settings. Most art therapists report that their practice is underpinned by psychodynamically grounded understandings of psychosis. However, rather than seek to explore underlying dynamics, art therapists typically adopt a non-directive approach encouraging patients to use image making to express feelings and reflect on these in a concrete way to develop self-understanding. While three-quarters of respondents reported that their work was valued by colleagues, less than half considered art therapy well understood by colleagues or integrated with other services.
People diagnosed with schizophrenia have limited access to art therapy in NHS settings. Further research is needed to understand the experience and outcomes of art therapy to support its meaningful integration within the spectrum of care required to meet the needs of people with schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
32J Am Med Dir Assoc 2012 Sep 13: 618-25
PMID22796361
TitleTesting the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0.
AbstractTo test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.
The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHS) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ?30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and schizophrenia (m-SADS) was measured with weighted kappas (?). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.
The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted ? = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted ? = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.
Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
33Trials 2012 -1 13: 223
PMID23171601
TitleThe effects of reducing worry in patients with persecutory delusions: study protocol for a randomized controlled trial.
AbstractOur approach to advancing the treatment of psychosis is to focus on key single symptoms and develop interventions that target the mechanisms that maintain them. In our theoretical research we have found worry to be an important factor in the development and maintenance of persecutory delusions. Worry brings implausible ideas to mind, keeps them there, and makes the experience distressing. Therefore the aim of the trial is to test the clinical efficacy of a cognitive-behavioral intervention for worry for patients with persecutory delusions and determine how the worry treatment might reduce delusions.
An explanatory randomized controlled trial--called the Worry Intervention Trial (WIT)--with 150 patients with persecutory delusions will be carried out. Patients will be randomized to the worry intervention in addition to standard care or to standard care. Randomization will be carried out independently, assessments carried out single-blind, and therapy competence and adherence monitored. The study population will be individuals with persecutory delusions and worry in the context of a schizophrenia spectrum diagnosis. They will not have responded adequately to previous treatment. The intervention is a six-session cognitive-behavioral treatment provided over eight weeks. The control condition will be treatment as usual, which is typically antipsychotic medication and regular appointments. The principal hypotheses are that a worry intervention will reduce levels of worry and that it will also reduce the persecutory delusions. Assessments will be carried out at 0 weeks (baseline), 8 weeks (post treatment) and 24 weeks (follow-up). The statistical analysis strategy will follow the intention-to-treat principle and involve the use of linear mixed models to evaluate and estimate the relevant between- and within-subjects effects (allowing for the possibility of missing data). Both traditional regression and newer instrumental variables analyses will examine mediation. The trial is funded by the UK Medical Research Council (MRC)/NHS National Institute of Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) Programme.
This will be the first large randomized controlled trial specifically focused upon persecutory delusions. The project will produce a brief, easily administered intervention that can be readily used in mental health services.
Current Controlled Trials ISRCTN23197625.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
34BMC Psychiatry 2012 -1 12: 121
PMID22905674
TitleAssociations of homelessness and residential mobility with length of stay after acute psychiatric admission.
AbstractA small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures.
Cross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression.
Residential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor.
Homelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
35Int J Nurs Stud 2012 Jan 49: 72-83
PMID21899840
TitleMental health nurses' attitudes towards the physical health care of people with severe and enduring mental illness: the development of a measurement tool.
AbstractIt is well established that people with schizophrenia and related serious mental illnesses die prematurely and have significantly higher medical co-morbidity compared with the general population. Mental health nurses have a key role in improving the physical health of patients but their attitudes to this aspect of their role have not been systematically examined.
To develop and validate a measure of mental nurses' attitudes towards physical health care.
The measurement tool was developed from a literature review, focus groups and responses to a postal questionnaire.
All registered nursing staff working within a NHS mental health trust in the UK were sent the questionnaire and 585 (52%) staff responded.
Completed questionnaires were analysed by standard descriptive statistical methods. Exploratory factor analysis (principal component analysis) was used to examine and reduce attitude items to a coherent and parsimonious scale.
A 28-item measure comprised of four factors accounted for 42% of the variance. The factor solution appeared to provide meaningful dimensions, and the internal consistency of the measure and of its derived subscales was adequate (Cronbach's alpha between 0.76 and 0.61). The factors were labelled nurses' attitudes to involvement in physical health care; nurses' confidence in delivering physical health care; perceived barriers to physical health care delivery and nurses' attitudes to smoking. Validity was established by associations between the total scale and subscales with pre-determined respondent variables.
The Physical Health Attitude Scale for mental health nurses (PHASe) is a first attempt to develop a valid and reliable measure of this important area. The initial development methods and its testing in a large sample provide indications of content and construct validity. Further testing in different samples and consequent refinement are necessary, however the PHASe appears to be a useful tool for measuring attitudes among this professional group and evaluating the effects of professional development.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
36Eur. Psychiatry 2012 Jan 27: 33-42
PMID21570814
TitleType-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up.
AbstractPhysical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.
During 2000-2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.
The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.
schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
37Eur. Psychiatry 2012 Jan 27: 33-42
PMID21570814
TitleType-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up.
AbstractPhysical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.
During 2000-2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.
The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.
schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
38Eur. Psychiatry 2012 Jan 27: 33-42
PMID21570814
TitleType-2 diabetes mellitus in schizophrenia: increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up.
AbstractPhysical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.
During 2000-2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.
The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.
schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
39Appl Health Econ Health Policy 2013 Apr 11: 95-106
PMID23494934
TitleThe cost effectiveness of long-acting/extended-release antipsychotics for the treatment of schizophrenia: a systematic review of economic evaluations.
AbstractAntipsychotic medication is the mainstay of treatment in schizophrenia. Long-acting medication has potential advantages over daily medication in improving compliance and thus reducing hospitalization and relapse rates. The high acquisition and administration costs of such formulations raise the need for pharmacoeconomic evaluation.
The aim of this article is to provide a comprehensive review of the available evidence on the cost effectiveness of long-acting/extended-release antipsychotic medication and critically appraise the strength of evidence reported in the studies from a methodological viewpoint.
Relevant studies were identified by searching five electronic databases: PsycINFO, MEDLINE, EMBASE, the NHS Economic Evaluation Database and the Health Technology Assessment database (HTA). Search terms included, but were not limited to, 'long-acting injection', 'economic evaluation', 'cost-effectiveness' and 'cost-utility'. No limits were applied for publication dates and language. Full economic evaluations on long-acting/extended-release antipsychotics were eligible for inclusion. Observational studies and clinical trials were also checked for cost-effectiveness information. Conference abstracts and poster presentations on the cost effectiveness of long-acting antipsychotics were excluded. Thirty-two percent of identified studies met the selection criteria. Pertinent abstracts were reviewed independently by two reviewers. Relevant studies underwent data extraction by one reviewer and were checked by a second, with any discrepancies being clarified during consensus meetings. Eligible studies were assessed for methodological quality using the quality checklist for economic studies recommended by the NICE guideline on interventions in the treatment and management of schizophrenia.
After applying the selection criteria, the final sample consisted of 28 studies. The majority of studies demonstrated that risperidone long-acting injection, relative to oral or other long-acting injectable drugs, was associated with cost savings and additional clinical benefits and was the dominant strategy in terms of cost effectiveness. However, olanzapine in either oral or long-acting injectable formulation dominated risperidone long-acting injection in a Slovenian and a US study. Furthermore, in two UK studies, the use of long-acting risperidone increased the hospitalization days and overall healthcare costs, relative to other atypical or typical long-acting antipsychotics. Finally, paliperidone extended-release was the most cost-effective treatment compared with atypical oral or typical long-acting formulations. From a methodological viewpoint, most studies employed decision analytic models, presented results using average cost-effectiveness ratios and conducted comprehensive sensitivity analyses to test the robustness of the results.
Variations in study methodologies restrict consistent and direct comparisons across countries. The exclusion of a large body of potentially relevant conference abstracts as well as some papers being unobtainable may have increased the likelihood of misrepresenting the overall cost effectiveness of long-acting antipsychotics. Finally, the review process was restricted to qualitative assessment rather than a quantitative synthesis of results, which could provide more robust conclusions.
Atypical long-acting (especially risperidone)/extended-release antipsychotic medication is likely to be a cost-effective, first-line strategy for managing schizophrenia, compared with long-acting haloperidol and other oral or depot formulations, irrespective of country-specific differences. However, inconsistencies in study methodologies and in the reporting of study findings suggest caution needs to be applied in interpreting these findings.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
40Methods Mol. Biol. 2013 -1 964: 3-13
PMID23296774
TitleDetection of cell surface dopamine receptors.
AbstractDopamine receptors are a class of metabotropic G protein-coupled receptors. Plasma membrane expression is a key determinant of receptor signaling, and one that is regulated both by extra and intracellular cues. Abnormal dopamine receptor signaling is implicated in several neuropsychiatric disorders, including schizophrenia and attention deficit hyperactivity disorder, as well as drug abuse. Here, we describe in detail the application of two complementary applications of protein biotinylation and enzyme-linked immunoabsorbent assay (ELISA) for detecting and quantifying levels of dopamine receptors expressed on the cell surface. In the biotinylation method, cell surface receptors are labeled with Sulfo-NHS-biotin. The charge on the sulfonyl facilitates water solubility of the reactive biotin compound and prevents its diffusion across the plasma membrane. In the ELISA method, surface labeling is achieved with antibodies specific to extracellular epitopes on the receptors, and by fixing the cells without detergent such that the plasma membrane remains intact.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
41Trials 2013 -1 14: 323
PMID24099414
TitleStudy on psychoeducation enhancing results of adherence in patients with schizophrenia (SPERA-S): study protocol for a randomized controlled trial.
AbstractPoor adherence to pharmacotherapy negatively affects the course and the outcome of schizophreniaspectrum psychoses, enhancing the risk of relapse. Falloon and coworkers developed a Psychoeducation Program aimed at improving communication and problem-solving abilities in patients and their families. This study set out to evaluate changes in adherence to pharmacotherapy in patients diagnosed with schizophrenia-spectrum psychoses, by comparing one group exposed to the Falloon Psychoeducation Program (FPP) with another group exposed to family supportive therapy with generic information on the disorders.
340 patients diagnosed with schizophrenia and related disorders according to standardized criteria from 10 participating units distributed throughout the Italian National Health System (NHS), will be enrolled with 1:1 allocation by the method of blocks of randomized permutations. Patients will be reassessed at 6, 12 and 18 months after start of treatment (duration: 6 months).The primary objective is to evaluate changes in adherence to pharmacotherapy after psychoeducation. Adherence will be assessed at three-month intervals by measuring blood levels of the primary prescribed drug using high pressure liquid chromatography, and via the Medication Adherence Questionnaire and a modified version of the Adherence Interview. Secondary objectives are changes in the frequency of relapse and readmission, as the main indicator of the course of the disorder.Enrolled patients will be allocated to the FPP (yes/no) randomly, 1:1, in a procedure controlled by the coordinating unit; codes will be masked until the conclusion of the protocol (or the occurrence of a severe negative event). The raters will be blind to treatment allocation and will be tested for blinding after treatment completion. Intention-to-treat will be applied in considering the primary and secondary outcomes. Multiple imputations will be applied to integrate the missing data. The study started recruitment in February 2013; the total duration of the study is 27 months.
If the psychoeducation program proves effective in improving adherence to pharmacotherapy and in reducing relapse and readmissions, its application could be proposed as a standard adjunctive psychosocial treatment within the Italian NHS.
Protocol Registration System of ClinicalTrials.gov NCT01433094; registered on 20 August 2011; first patient was randomized on 12 February 2013.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
42Trials 2013 -1 14: 214
PMID23845104
TitleThe effects of using cognitive behavioural therapy to improve sleep for patients with delusions and hallucinations (the BEST study): study protocol for a randomized controlled trial.
AbstractPatients with psychosis frequently report difficulties getting or staying asleep (insomnia). Dissatisfaction with sleep is high. Insomnia should be treated in this group, but typically it is not even assessed. Importantly, recent evidence indicates that insomnia triggers and exacerbates delusions and hallucinations. The clinical implication is that if the insomnia is treated then the psychotic symptoms will significantly lessen. In a case series with 15 patients with persecutory delusions resistant to previous treatment this is exactly what we found: cognitive behavioural therapy for insomnia (CBT-I) led to large reductions in both the insomnia and delusions. The clear next step is a pilot randomized controlled test. The clinical aim is to test whether CBT-I can reduce both insomnia and psychotic symptoms. The trial will inform decisions for a definitive large-scale evaluation.
We will carry out a randomized controlled trial (the Better Sleep Trial, or the BEST study) with 60 patients with distressing delusions or hallucinations in the context of a schizophrenia spectrum diagnosis. Half of the participants will be randomized to receive CBT-I, in addition to their standard treatment, for up to eight sessions over 12 weeks. The other half will continue with treatment as usual. Blind assessments will take place at 0 weeks, 12 weeks (post-treatment) and 24 weeks (follow-up). The primary outcome hypotheses are that CBT-I added to treatment as usual will improve sleep, delusions and hallucinations compared with only treatment as usual. All main analyses will be carried out at the end of the last follow-up assessments and will be based on the intention-to-treat principle. The trial is funded by the NHS National Institute for Health Research (NIHR) Research for Patient Benefit Programme. Data collection will be complete by the end of 2014.
This will be the first controlled test of CBT-I for patients with delusions and hallucinations. It will provide significant evidence for an easily administered intervention that is likely to prove very popular with patients experiencing the difficult-to-treat problems of delusions and hallucinations.
Current Controlled Trials ISRCTN 33695128.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
43BMC Health Serv Res 2013 -1 13: 270
PMID23844779
TitleSocial Firms as a means of vocational recovery for people with mental illness: a UK survey.
AbstractEmployment is associated with better quality of life and wellbeing in people with mental illness. Unemployment is associated with greater levels of psychological illness and is viewed as a core part of the social exclusion faced by people with mental illness. Social Firms offer paid employment to people with mental illness but are under-investigated in the UK. The aims of this phase of the Social Firms A Route to Recovery (SoFARR) project were to describe the availability and spread of Social Firms across the UK, to outline the range of opportunities Social Firms offer people with severe mental illness and to understand the extent to which they are employed within these firms.
A UK national survey of Social Firms, other social enterprises and supported businesses was completed to understand the extent to which they provide paid employment for the mentally ill. A study-specific questionnaire was developed. It covered two broad areas asking employers about the nature of the Social Firm itself and about the employees with mental illness working there.
We obtained returns from 76 Social Firms and social enterprises / supported businesses employing 692 people with mental illness. Forty per cent of Social Firms were in the south of England, 24% in the North and the Midlands, 18% in Scotland and 18% in Wales. Other social enterprises/supported businesses were similarly distributed. Trading activities were confined mainly to manufacturing, service industry, recycling, horticulture and catering. The number of employees with mental illness working in Social Firms and other social enterprises/supported businesses was small (median of 3 and 6.5 respectively). Over 50% employed people with schizophrenia or bipolar disorder, though the greatest proportion of employees with mental illness had depression or anxiety. Over two thirds of Social Firms liaised with mental health services and over a quarter received funding from the NHS or a mental health charity. Most workers with mental illness in Social Firms had been employed for over 2 years.
Social Firms have significant potential to be a viable addition to Individual Placement and Support (IPS), supporting recovery orientated services for people with the full range of mental disorders. They are currently an underdeveloped sector in the UK.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
44Int. J. Clin. Pract. 2013 Feb 67: 170-80
PMID23305478
TitleAre specific initiatives required to enhance prescribing of generic atypical antipsychotics in Scotland?: International implications.
AbstractNational and regional authorities in Scotland have introduced multiple measures to appreciably enhance prescribing efficiency for the proton pump inhibitors (PPIs), statins and renin-angiotensin inhibitor drugs. Generic oral risperidone recently became available in Scotland; however, schizophrenia is a complex disease with advice from respected authorities suggesting that treatment should be individualised.
To assess (i) changes in atypical antipsychotic drug (AAP) utilisation and expenditure following the availability of oral generic risperidone in Scotland; (ii) to determine (a) current INN prescribing rates for risperidone following generic availability and (b) decrease in expenditure/DDD for generic risperidone; (iii) to suggest additional measures that could possibly be introduced in Scotland to further enhance prescribing of generic AAPs; and (iv) to provide guidance to NHS Scotland as well as other European authorities on the implications.
Retrospective observational study and an interrupted time series design.
No appreciable change in the utilisation patterns of risperidone pre- and postgeneric availability. Appreciable INN prescribing averaged 93-98% of total oral risperidone. Generic risperidone was 84% below prepatent loss prices by study end, reducing annual expenditure for oral risperidone in 2010 by GB£3.19mn compared with prepatent loss situation. However, overall expenditure on AAPs increased by 42% from 2005 to 2010.
As expected, there was no change in utilisation patterns for risperidone, although potential to influence prescribing patterns. Continued high INN prescribing suggests no problems with generic risperidone in practice. Costs will start to decrease as more AAPs lose their patents (olanzapine and quetiapine). There is the possibility to accelerate this reduction through educational activities.
There is potential to realise some savings with generic AAPs. However, this is limited by the complexity of the disease area. Any measures introduced must aim at increasing the prescribing of generic AAPs first line in suitable patients.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
45J Psychiatr Res 2013 Dec 47: 1940-8
PMID24060266
TitleComorbid substance use disorders with other Axis I and II mental disorders among treatment-seeking Asian Americans, Native Hawaiians/Pacific Islanders, and mixed-race people.
AbstractLittle is known about behavioral healthcare needs of Asian Americans (AAs), Native Hawaiians/Pacific Islanders (NHS/PIs), and mixed-race people (MRs)-the fastest growing segments of the U.S. population. We examined substance use disorder (SUD) prevalences and comorbidities among AAs, NHS/PIs, and MRs (N = 4572) in a behavioral health electronic health record database. DSM-IV diagnoses among patients aged 1-90 years who accessed behavioral healthcare from 11 sites were systematically captured: SUD, anxiety, mood, personality, adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic/schizophrenic, sleep, and somatoform diagnoses. Of all patients, 15.0% had a SUD. Mood (60%), anxiety (31.2%), adjustment (30.9%), and disruptive (attention deficit-hyperactivity, conduct, oppositional defiant, disruptive behavior diagnosis, 22.7%) diagnoses were more common than others (psychotic 14.2%, personality 13.3%, other childhood-onset 11.4%, impulse-control 6.6%, cognitive 2.8%, eating 2.2%, somatoform 2.1%). Less than 1% of children aged <12 years had SUD. Cannabis diagnosis was the primary SUD affecting adolescents aged 12-17. MRs aged 35-49 years had the highest prevalence of cocaine diagnosis. Controlling for age at first visit, sex, treatment setting, length of treatment, and number of comorbid diagnoses, NHS/PIs and MRs were about two times more likely than AAs to have ? 2 SUDs. Regardless of race/ethnicity, personality diagnosis was comorbid with SUD. NHS/PIs with a mood diagnosis had elevated odds of having SUD. Findings present the most comprehensive patterns of mental diagnoses available for treatment-seeking AAs, NHS/PIs, and MRs in the real-world medical setting. In-depth research is needed to elucidate intraracial and interracial differences in treatment needs.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
46J. Psychopharmacol. (Oxford) 2014 Mar 28: 665-670
PMID24595968
TitleAssociation of tardive dyskinesia with variation in CYP2D6: Is there a role for active metabolites?
AbstractThe aim of this study was to examine whether there was an association between tardive dyskinesia (TD) and number of functional CYP2D6 genes.
A Caucasian sample of 70 patients was recruited in 1996-1997 from South London and Maudsley National Health Service (NHS) Foundation Trust, UK. Subjects had a DSM-IIIR diagnosis of schizophrenia and were treated with typical antipsychotics at doses equivalent to at least 100 mg chlorpromazine daily for at least 12 months prior to assessment. All patients were genotyped for CYP2D6 alleles*3-5, *41, and for amplifications of the gene.
There were 13 patients with TD. The mean (standard deviation (SD)) years of duration of antipsychotic treatment in TD-positive was 15.8 (7.9) vs TD-negative 11.1 (7.4) (p=0.04). Increased odds of experiencing TD were associated with increased ability to metabolize CYP2D6, as measured by genotypic category (odds ratio (OR)=4.2), increasing duration in treatment (OR=1.0), and having drug-induced Parkinsonism (OR=9.7).
We found a significant association between CYP2D6 genotypic category and TD with the direction of effect being an increase in the number of functional CYP2D6 genes being associated with an increased risk of TD. This is the first study to examine the association between TD and CYP2D6 in Caucasians with this number of genotypic categories. In the future, metabolomics may be utilized in the discovery of biomarkers and novel drug targets.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
47Eur Arch Psychiatry Clin Neurosci 2014 Feb 264: 3-28
PMID23942824
TitlePhysical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions.
Abstractschizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ?1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
48Eur Arch Psychiatry Clin Neurosci 2014 Feb 264: 3-28
PMID23942824
TitlePhysical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions.
Abstractschizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ?1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
49Health Technol Assess 2014 Jan 18: 1-74
PMID24405570
TitleThe effectiveness of sexual health interventions for people with severe mental illness: a systematic review.
AbstractSevere mental illnesses (SMIs), such as schizophrenia and bipolar disorder, persist over time and can cause extensive disability leading to impairments in social and occupational functioning. People with SMI have higher morbidity and mortality due to physical illness than the general population and may be more likely to engage in high-risk sexual behaviour (e.g. unprotected intercourse, having multiple partners, involvement in the sex trade and illicit drug use), putting them at risk of poorer sexual health outcomes including sexually transmitted infections. Sexual health promotion interventions, developed and implemented for people with SMI, may improve participants' knowledge, attitudes, beliefs or behavioural practices and could lead to a reduction in risky sexual behaviour.
To evaluate the effectiveness of sexual health interventions for people with SMI compared with usual care and their applicability to the UK NHS setting.
Thirteen electronic databases were searched from inception to December 2012. All controlled trials (randomised or non-randomised) that met the following criteria were included: any sexual health promotion intervention or combination of interventions intended to change the knowledge, attitudes, beliefs, behaviours or practices of individuals with SMI (defined as adults aged ??18 years who have received a diagnosis of schizophrenia or bipolar disorder) living in the community.
A systematic review of the clinical evidence was undertaken following recommended guidelines. Data were tabulated and discussed in a narrative review.
Thirteen randomised controlled studies met the inclusion criteria. The methodological quality of the included studies varied considerably, with only a minority of studies (n?=?2) being considered as having very few methodological limitations. Despite wide variations in the study populations, interventions, comparators and outcomes, four studies showed significant improvements in all measured sexual risk behaviour outcomes (e.g. human immunodeficiency virus knowledge and behaviour change) in the intervention groups compared with the control groups. In contrast, four studies found significant improvements in the intervention groups for some outcomes only and three studies found significant improvements in certain subgroups only, based on either gender or ethnicity. Finally, two studies reported no significant differences in any sexual risk behaviour outcomes between the intervention and control groups. Moreover, positive findings were not consistently sustained at follow-up in many studies.
Little detail was provided in the studies regarding the content of interventions, how they were delivered and by whom, making replication or generalisability difficult.
Owing to the large between-study variability (especially in the populations, interventions, comparators and reported outcomes) and mixed results, there is insufficient evidence to fully support or reject the identified sexual health interventions for people with SMI. In addition, there are considerable uncertainties around the generalisability of these findings to the UK setting. Further research recommendations include well-designed, UK-based trials of sexual health interventions for people with SMI as well as training and support for staff implementing sexual health interventions.
PROSPERO number CRD42013003674.
The National Institute for Health Research Health Technology Assessment Programme.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
50Psychiatr Bull (2014) 2014 Apr 38: 54-7
PMID25237499
TitleSocioeconomic status and prescribing for schizophrenia: analysis of 3200 cases from the Glasgow Psychosis Clinical Information System (PsyCIS).
AbstractAims and method To investigate whether socioeconomic status influenced rates of depot medication prescribing, polypharmacy (more than two psychotropic medications), newer (second-generation) antipsychotic prescribing and clozapine therapy. Postcodes, Scottish Index of Multiple Deprivation (SIMD) categories and current medication status were ascertained. Patients in the most deprived SIMD groups (8-10 combined) were compared with those in the most affluent SIMD groups (1-3 combined). Results Overall, 3200 patients with ICD-10 schizophrenia were identified. No clear relationship between socioeconomic status and any of the four prescribing areas was identified, although rates of depot medication use in deprived areas were slightly higher. Clinical implications Contrary to our hypothesis, there was no evidence that patients with schizophrenia within NHS Greater Glasgow and Clyde who live in more deprived communities had different prescribing experiences from patients living in more affluent areas.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
51Behav Cogn Psychother 2014 Mar 42: 199-210
PMID23360683
TitleA mixed-methods evaluation of a pilot psychosocial intervention group for older people with schizophrenia.
AbstractThere is a strong evidence base for psychological treatments in younger adults with schizophrenia, but limited work has been done on adapting these interventions for older people.
We describe a study of a pilot psychosocial intervention group specifically designed to meet the needs of older people with schizophrenia in NHS settings.
We used a mixed-methods approach to evaluate the group. We assessed feasibility and acceptability by monitoring uptake and retention in the study. We used a within groups design comparing participants on a range of potentially relevant outcomes at baseline and posttreatment. Treatment acceptability was also assessed by semi-structured interviews conducted at the end of treatment.
We recruited 11 participants to the study and 7 of these completed the majority of the group sessions. At a group level participants made improvements in self-esteem and negative symptoms that were statistically significant even in this small sample. Feedback interviews suggested that participants valued the social contact provided by the group and made actual changes in their day-to-day lives as a result of attending.
The intervention could offer help with some of the secondary disability associated with the diagnosis of schizophrenia and is acceptable to older adults. Further evaluation is, however, warranted.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
52Ther Adv Psychopharmacol 2014 Dec 4: 247-56
PMID25489476
TitleFactors associated with non evidence-based prescribing of antipsychotics.
AbstractNon evidence-based prescribing of antipsychotics is common in the UK and internationally with high doses and polypharmacy the norm. These practices often remain even after systematic attempts are made to change. We aimed to establish which factors are linked to antipsychotic prescribing quality so we can identify and target patients for interventions to improve quality and allow us to understand further the drivers of non evidence-based prescribing.
A cross-sectional survey with a collection of factors potentially affecting antipsychotic prescribing quality outcomes was carried out in eight secondary care units in England. Participants were inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose, polypharmacy, type and route were the main outcome measures.
Data were collected for 1198 patients. Higher total dose was associated with greater weight, higher number of previous admissions, longer length of admission, noncompliance with medication and use of an atypical antipsychotic. A lower total dose was associated with clozapine use. Polypharmacy was associated with not being a patient at the South London and Maudsley NHS Trust centre, the subject having a forensic history, a greater number of previous admissions and higher total dose. Younger age, not being detained under a Mental Health Act section, atypical antipsychotic use and oral route were predictors of antipsychotic monotherapy. Atypical antipsychotic use was associated with oral route, higher total dose, being administered only one antipsychotic, having had fewer previous antipsychotics and no anticholinergic use. Use of the oral route was associated with not being sectioned under the Mental Health Act, atypical antipsychotic use, younger age, non-schizophrenia diagnosis, fewer previous admissions and a lower total dose.
In patients with chronic illness who are detained, heavier, noncompliant, not taking clozapine and on a depot antipsychotic, prescribers use larger doses and antipsychotic polypharmacy. We found that use of percentage of licensed maximum doses favours typical antipsychotics arbitrarily, and that high doses and polypharmacy are inextricably linked.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
53Soc Sci Med 2014 Nov 120: 243-51
PMID25262312
TitleHospital admissions for severe mental illness in England: changes in equity of utilisation at the small area level between 2006 and 2010.
AbstractSevere Mental Illness (SMI) encompasses a range of chronic conditions including schizophrenia, bipolar disorder and psychoses. Patients with SMI often require inpatient psychiatric care. Despite equity being a key objective in the English National Health Service (NHS) and in many other health care systems worldwide, little is known about the socio-economic equity of hospital care utilisation for patients with SMI and how it has changed over time. This analysis seeks to address that gap in the evidence base. We exploit a five-year (2006-2010) panel dataset of admission rates at small area level (n=162,410). The choice of control variables was informed by a systematic literature search. To assess changes in socio-economic equity of utilisation, OLS-based standardisation was first used to conduct analysis of discrete deprivation groups. Geographical inequity was then illustrated by plotting standardised and crude admission rates at local purchaser level. Lastly, formal statistical tests for changes in socio-economic equity of utilisation were applied to a continuous measure of deprivation using pooled negative binomial regression analysis, adjusting for a range of risk factors. Our results suggest that one additional percentage point of area income deprivation is associated with a 1.5% (p<0.001) increase in admissions for SMI after controlling for population size, age, sex, prevalence of SMI in the local population, as well as other need and supply factors. This finding is robust to sensitivity analyses, suggesting that a pro-poor inequality in utilisation exists for SMI-related inpatient services. One possible explanation is that the supply or quality of primary, community or social care for people with mental health problems is suboptimal in deprived areas. Although there is some evidence that inequity has reduced over time, the changes are small and not always robust to sensitivity analyses.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
54BMC Psychiatry 2014 -1 14: 213
PMID25085220
TitleSuicide completion in secondary mental healthcare: a comparison study between schizophrenia spectrum disorders and all other diagnoses.
AbstractSuicide completion is a tragic outcome in secondary mental healthcare. However, the extent to which demographic and clinical characteristics, suicide method and service use-related factors vary across psychiatric diagnoses remains poorly understood, particularly regarding differences between 'schizophrenia spectrum disorders (SSD)' and 'all other diagnoses', which may have implications for suicide prevention in high risk groups.
308 patients who died by suicide over 2007-2011 were identified from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register. Demographic, clinical, services use-related factors, 'full risk assessment' ratings and the Health of the Nation Outcome Scale (HONOS) scores were compared across psychiatric diagnoses. Specifically, differences between patients with and without SSD were investigated.
Patients with SSD ended their lives at a younger age, were more frequently of Black ethnicity and had higher levels of social deprivation than other diagnoses. Also, these patients were more likely to have HONOS and 'risk assessment' completed. However, patients who had no SSD scored significantly higher on 'self-injury' and 'depression' HONOS items and they were more likely to have the following 'risk assessment' items: 'suicidal ideation', 'hopelessness', 'feeling no control of life', 'impulsivity' and 'significant loss'. Of note, 'disengagement' was more common in patients with SSD, although they had been seen by the staff closer to the time of suicide than in all-other diagnoses. Whilst 'hanging' was the most common suicide method amongst patients with non-SSD, most service users with a SSD diagnosis used 'jumping' (from heights or in front of a vehicle).
Suicide completion characteristics varied between SSD and other diagnoses in patients receiving secondary mental healthcare. In particular, although clinicians tend to more frequently recognize suicide risk as a focus of concern in patients who have SSD, who are therefore more likely to have a detailed risk assessment documented; 'known' suicide risk factors appear to be more relevant in patients with non-SSD. Hence, the classic suicide prevention model might be of little use for SSD.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
55Int J Eat Disord 2014 Jul 47: 507-15
PMID24599787
TitleMortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009.
AbstractTo calculate mortality of people with eating disorders (ED) in England, relative to that of people of the same age and sex, between 2001 and 2009. We were specifically interested in mortality amongst adolescents and young adults (15-24 years), and older adults (25-44 years).
We analyzed a NHS Hospital Episode Statistics (HES) dataset for all England, linked to death registrations, to calculate age- and sex-specific discharge rates for people with a diagnosis of ED and their subsequent mortality by one year after discharge.
The standardized mortality ratio (SMR) for adolescents and young adults with a diagnosis of ED was 7.8 (95% confidence interval: 4.4-11.2). This compares with an SMR for people of the same age with schizophrenia of 10.2 (8.3-12.2), with bipolar disorder of 3.6 (1.1-6.1, and with depression of 4.5 (3.6-5.3). Of the ED, the SMR for anorexia nervosa (AN) in people aged 15-24 was 11.5 (6.0-17.0), for bulimia nervosa (BN) was 4.1 (0-8.7), and eating disorders not otherwise specified (ED NOS) was 1.4 (0-4.0). For older adults aged 25-44 years, the SMR for ED was 10.7 (7.7-13.6). Specifically, for AN was 14.0 (9.2-18.8), for BN was 7.7 (3.5-11.9), and ED NOS was 4.7 (1.4-8.0), for schizophrenia was 7.3 (6.6-7.9), for bipolar disorder was 4.3 (3.5-5.1) and for depression was 4.9 (4.6-5.3). No deaths were recorded below 15 years of age.
This study confirms the high SMR associated with ED, notably with anorexia and bulimia.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
56J R Soc Med 2014 Feb 107: 194-204
PMID24526464
TitleRisk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage.
AbstractPsychiatric illnesses are known risk factors for self-harm but associations between self-harm and physical illnesses are less well established. We aimed to stratify selected chronic physical and psychiatric illnesses according to their relative risk of self-harm.
Retrospective cohort studies using a linked dataset of Hospital Episode Statistics (HES) for 1999-2011.
Individuals with selected psychiatric or physical conditions were compared with a reference cohort constructed from patients admitted for a variety of other conditions and procedures.
All admissions and day cases in National Health Service (NHS) hospitals in England.
Hospital episodes of self-harm. Rate ratios (RRs) were derived by comparing admission for self-harm between cohorts.
The psychiatric illnesses studied (depression, bipolar disorder, alcohol abuse, anxiety disorders, eating disorders, schizophrenia and substance abuse) all had very high RRs (> 5) for self-harm. Of the physical illnesses studied, an increased risk of self-harm was associated with epilepsy (RR?=?2.9, 95% confidence interval [CI] 2.8-2.9), asthma (1.8, 1.8-1.9), migraine (1.8, 1.7-1.8), psoriasis (1.6, 1.5-1.7), diabetes mellitus (1.6, 1.5-1.6), eczema (1.4, 1.3-1.5) and inflammatory polyarthropathies (1.4, 1.3-1.4). RRs were significantly low for cancers (0.95, 0.93-0.97), congenital heart disease (0.9, 0.8-0.9), ulcerative colitis (0.8, 0.7-0.8), sickle cell anaemia (0.7, 0.6-0.8) and Down's syndrome (0.1, 0.1-0.2).
Psychiatric illnesses carry a greatly increased risk of self-harm as well as of suicide. Many chronic physical illnesses are also associated with an increased risk of both self-harm and suicide. Identifying those at risk will allow provision of appropriate monitoring and support.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
57Acta Psychiatr Scand 2014 Jul 130: 16-24
PMID24004162
TitlePractitioner attitudes to clozapine initiation.
AbstractClozapine is the most effective antipsychotic for treatment-resistant schizophrenia. It is recommended as third-line treatment for schizophrenia in national and local guidelines. Despite this, it is underutilised. This survey aimed to clarify barriers to prescribing and elucidate factors that may improve patient access to clozapine.
A questionnaire was made available to all staff members at South London and Maudsley NHS Foundation Trust.
In total, 144 clinical staff completed the questionnaire. The majority (81%) of respondents were 'fairly' or 'very' familiar with clozapine prescribing guidelines. Barriers to prescribing most commonly stated as being 'very frequently' a problem were patient concerns about tolerability of clozapine or patient refusal to adhere to blood test monitoring. Staff members also felt medical complications frequently prevented clozapine prescription. Dedicated staff or day hospital placements devoted to clozapine initiation were identified as factors most likely to increase prescribing of clozapine.
Professionals identified the dominant barriers to prescribing as being patient focussed - refusal of blood test monitoring or concerns about tolerability. Clinician fears about compliance or medical complications were also important. The development of out-patient services specifically tasked with initiating clozapine may help to increase the frequency of prescribing of clozapine earlier in treatment than is currently seen.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
58J Psychiatr Ment Health Nurs 2014 Mar 21: 121-7
PMID23676123
TitleProvision of health promotion programmes to people with serious mental illness: a mapping exercise of four South London boroughs.
Abstract
People with serious mental illness (SMI) are at increased risk of developing various physical health diseases, contributing to significantly reduced life expectancies compared with the general population. In light of this, the Department of Health have set the physical health of people with mental health problems as a priority for improvement. Additionally, the UK government encourages the NHS and local authorities to develop health promotion programmes (HPPs) for people with SMI.
To document how many and what types of HPPs were available to people with SMI across four South London boroughs, UK.
We found 145 HPPs were available to people with SMI across the four boroughs, but with an inequitable distribution. We also found that certain HPPs set admission criteria that were likely to act as a barrier to improving health.
A more integrated approach of documenting and providing information regarding the provision of HPPs for or inclusive of people with SMI is needed.
People with serious mental illness (SMI) such as schizophrenia, schizoaffective disorders and bipolar disorder are at increased risk of developing diabetes, cardiovascular disease and respiratory disease, contributing to significantly reduced life expectancies. As a result, emphasis has been placed on developing Health Promotion Programmes (HPPs) to modify the risk of poor physical health in SMI. We examined how many and what types of HPPs are available for or inclusive of people with SMI across four borough in South London, UK. A cross-sectional mapping study was carried out to identify the number of HPPs available to people with SMI. We found 145 HPPs available to people with SMI existed across the four boroughs but with an inequitable distribution, which in some boroughs we anticipate may not meet need. In some cases, HPPs set admission conditions which were likely to further impede access. We recommend that accurate and readily available information on the provision of HPPs for or inclusive of people with SMI is needed.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
59Health Technol Assess 2015 Mar 19: 1-148, v-vi
PMID25827850
TitleSmoking Cessation Intervention for severe Mental Ill Health Trial (SCIMITAR): a pilot randomised control trial of the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation service.
AbstractThere is a high prevalence of smoking among people who experience severe mental ill health (SMI). Helping people with disorders such as bipolar illness and schizophrenia to quit smoking would help improve their health, increase longevity and also reduce health inequalities. Around half of people with SMI who smoke express an interest in cutting down or quitting smoking. There is limited evidence that smoking cessation can be achieved for people with SMI. Those with SMI rarely access routine NHS smoking cessation services. This suggests the need to develop and evaluate a behavioural support and medication package tailored to the needs of people with SMI.
The objective in this project was to conduct a pilot trial to establish acceptability of the intervention and to ensure the feasibility of recruitment, randomisation and follow-up. We also sought preliminary estimates of effect size in order to design a fully powered trial of clinical effectiveness and cost-effectiveness. The pilot should inform a fully powered trial to compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual general practitioner (GP) care for people with SMI.
A pilot pragmatic two-arm individually randomised controlled trial (RCT). Simple randomisation was used following a computer-generated random number sequence. Participants and practitioners were not blinded to allocation.
Primary care and secondary care mental health services in England.
Smokers aged >?18 years with a severe mental illness who would like to cut down or quit smoking.
A BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual GP care.
The primary outcome was carbon monoxide-verified smoking cessation at 12 months. Smoking-related secondary outcomes were reduction of number of cigarettes smoked, Fagerstrom test of nicotine dependence and motivation to quit (MTQ). Other secondary outcomes were Patient Health Questionnaire-9 items and Short Form Questionnaire-12 items to assess whether there were improvements or deterioration in mental health and quality of life. We also measured body mass index to assess whether or not smoking cessation was associated with weight gain. These were measured at 1, 6 and 12 months post randomisation.
The trial recruited 97 people aged 19-73 years who smoked between 5 and 60 cigarettes per day (mean 25 cigarettes). Participants were recruited from four mental health trusts and 45 GP surgeries. Forty-six people were randomised to the BSC intervention and 51 people were randomised to usual GP care. The odds of quitting at 12 months was higher in the BSC intervention (36% vs. 23%) but did not reach statistical significance (odds ratio 2.9; 95% confidence interval 0.8% to 10.5%). At 3 and 6 months there was no evidence of difference in self-reported smoking cessation. There was a non-significant reduction in the number of cigarettes smoked and nicotine dependence. MTQ and number of quit attempts all increased in the BSC group compared with usual care. There was no difference in terms of quality of life at any time point, but there was evidence of an increase in depression scores at 12 months for the BSC group. There were no serious adverse events thought likely to be related to the trial interventions. The pilot economic analysis demonstrated that it was feasible to carry out a full economic analysis.
It was possible to recruit people with SMI from primary and secondary care to a trial of a smoking cessation intervention based around behavioural support and medication. The overall direction of effect was a positive trend in relation to biochemically verified smoking cessation and it was feasible to obtain follow-up in a substantial proportion of participants. A definitive trial of a bespoke cessation intervention has been prioritised by the National Institute for Health Research (NIHR) and the SCIMITAR pilot trial forms a template for a fully powered RCT to examine clinical effectiveness and cost-effectiveness.
Current Controlled Trials ISRCTN79497236.
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment, Vol. 19, No. 25. See the NIHR Journals Library website for further project information.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
60Health Technol Assess 2015 Jul 19: 1-130
PMID26202542
TitlePsychological and psychosocial interventions for cannabis cessation in adults: a systematic review short report.
AbstractCannabis is the most commonly used illicit drug worldwide. Cannabis dependence is a recognised psychiatric diagnosis, often diagnosed via the Diagnostic and Statistical Manual of Mental Disorders criteria and the International Classification of Diseases, 10th Revision. Cannabis use is associated with an increased risk of medical and psychological problems. This systematic review evaluates the use of a wide variety of psychological and psychosocial interventions, such as motivational interviewing (MI), cognitive-behavioural therapy (CBT) and contingency management.
To systematically review the clinical effectiveness of psychological and psychosocial interventions for cannabis cessation in adults who use cannabis regularly.
Studies were identified via searches of 11 databases [MEDLINE, EMBASE, Cochrane Controlled Trials Register, Health Technology Assessment (HTA) database, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, NHS Economic Evaluation Database, PsycINFO, Web of Science Conference Proceedings Citation Index, ClinicalTrials.gov and metaRegister of Current Controlled Trials] from inception to February 2014, searching of existing reviews and reference tracking.
Randomised controlled trials (RCTs) assessing psychological or psychosocial interventions in a community setting were eligible. Risk of bias was assessed using adapted Cochrane criteria and narrative synthesis was undertaken. Outcomes included change in cannabis use, severity of cannabis dependence, motivation to change and intervention adherence.
The review included 33 RCTs conducted in various countries (mostly the USA and Australia). General population studies: 26 studies assessed the general population of cannabis users. Across six studies, CBT (4-14 sessions) significantly improved outcomes (cannabis use, severity of dependence, cannabis problems) compared with wait list post treatment, maintained at 9 months in the one study with later follow-up. Studies of briefer MI or motivational enhancement therapy (MET) (one or two sessions) gave mixed results, with some improvements over wait list, while some comparisons were not significant. Four studies comparing CBT (6-14 sessions) with MI/MET (1-4 sessions) also gave mixed results: longer courses of CBT provided some improvements over MI. In one small study, supportive-expressive dynamic psychotherapy (16 sessions) gave significant improvements over one-session MI. Courses of other types of therapy (social support group, case management) gave similar improvements to CBT based on limited data. Limited data indicated that telephone- or internet-based interventions might be effective. Contingency management (vouchers for abstinence) gave promising results in the short term; however, at later follow-ups, vouchers in combination with CBT gave better results than vouchers or CBT alone. Psychiatric population studies: seven studies assessed psychiatric populations (schizophrenia, psychosis, bipolar disorder or major depression). CBT appeared to have little effect over treatment as usual (TAU) based on four small studies with design limitations (both groups received TAU and patients were referred). Other studies reported no significant difference between types of 10-session therapy.
Included studies were heterogeneous, covering a wide range of interventions, comparators, populations and outcomes. The majority were considered at high risk of bias. Effect sizes were reported in different formats across studies and outcomes.
Based on the available evidence, courses of CBT and (to a lesser extent) one or two sessions of MI improved outcomes in a self-selected population of cannabis users. There was some evidence that contingency management enhanced long-term outcomes in combination with CBT. Results of CBT for cannabis cessation in psychiatric populations were less promising, but may have been affected by provision of TAU in both groups and the referred populations. Future research should focus on the number of CBT/MI sessions required and potential clinical effectiveness and cost-effectiveness of shorter interventions. CBT plus contingency management and mutual aid therapies warrant further study. Studies should consider potential effects of recruitment methods and include inactive control groups and long-term follow-up. TAU arms in psychiatric population studies should aim not to confound the study intervention.
This study is registered as PROSPERO CRD42014008952.
The National Institute for Health Research HTA programme.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
61Psychol Med 2015 -1 45: 2619-29
PMID25961431
TitleCardiovascular risk factors and metabolic syndrome in people with established psychotic illnesses: baseline data from the IMPaCT randomized controlled trial.
AbstractThe aims of the study were to determine the prevalence of cardiometabolic risk factors and establish the proportion of people with psychosis meeting criteria for the metabolic syndrome (MetS). The study also aimed to identify the key lifestyle behaviours associated with increased risk of the MetS and to investigate whether the MetS is associated with illness severity and degree of functional impairment.
Baseline data were collected as part of a large randomized controlled trial (IMPaCT RCT). The study took place within community mental health teams in five Mental Health NHS Trusts in urban and rural locations across England. A total of 450 randomly selected out-patients, aged 18-65 years, with an established psychotic illness were recruited. We ascertained the prevalence rates of cardiometabolic risk factors, illness severity and functional impairment and calculated rates of the MetS, using International Diabetes Federation (IDF) and National Cholesterol Education Program Third Adult Treatment Panel criteria.
High rates of cardiometabolic risk factors were found. Nearly all women and most men had waist circumference exceeding the IDF threshold for central obesity. Half the sample was obese (body mass index ? 30 kg/m2) and a fifth met the criteria for type 2 diabetes mellitus. Females were more likely to be obese than males (61% v. 42%, p < 0.001). Of the 308 patients with complete laboratory measures, 57% (n = 175) met the IDF criteria for the MetS.
In the UK, the prevalence of cardiometabolic risk factors in individuals with psychotic illnesses is much higher than that observed in national general population studies as well as in most international studies of patients with psychosis.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
62Transl Psychiatry 2015 -1 5: e698
PMID26670283
TitleAssociations between the schizophrenia susceptibility gene ZNF804A and clinical outcomes in psychosis.
AbstractWe sought to test the hypothesis that the rs1344706 A allele will be associated with worse clinical outcome in first-episode psychosis. A data linkage was set up between a large systematic study of first-episode psychosis and an electronic health-record case register at the South London and Maudsley NHS Foundation Trust--a large provider of secondary mental-health care. A sample of 291 patients, who presented with a first psychotic episode (ICD10 diagnoses F20-29 or F30-33) and in whom the rs1344706 genotype had been assayed, were followed to examine the duration of mental-health in-patient care during the 2 years following first service contact, as a primary outcome. Secondary outcome measures were whether or not an in-patient episode occurred and the number of in-patient episodes during this period. A strong association was found between the number of rs1344706 A alleles and the cumulative duration of mental-health in-patient stay over the 2 years since initial presentation. In the 84.2% who experienced an in-patient episode during this period, the mean duration of admission was an additional 38 days for each A allele increment. Therefore, in addition to its potential role as a risk factor for psychosis, the ZNF804A rs1344706 A allele is associated with worse clinical outcome.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
63Asian J Psychiatr 2015 Apr 14: 36-41
PMID25703039
TitleA cross sectional study of prevalence and correlates of current and past risks in schizophrenia.
AbstractThe growing burden of chronic often untreated mental illness has increased the importance of risk assessment in people suffering from major mental disorders.
The present study was undertaken to obtain prevalence of various risks and predictive factors for self-harm, violence and various other risks among randomly recruited schizophrenia subjects (N=270) on the basis of past history of their disorder.
Using a rigorous translation, back translation and acceptability process, a specially constructed semi-structured assessment interview, based on a prior NHS Trust risk assessment interview along with the Diagnostic Interview for Genetic Studies (DIGS), detailed information was obtained for various risks.
Risk of violence (historical) was reported among 65.55%, and risk of self-neglect among 53.33%, risk to others (47.41%), risk of coming to harm (24.07%), self-harm (22.59%), risk from others (11.85%), fire risk (2.96%). Risk of violence (historical) and risk to others was related to 'ever' having emotions related to harm and self-harm, 'current' emotions related to violence and poor compliance to treatment.
Regular risk assessment is essential to assess emotions related to violence and non-adherence to treatment. Assessment of risk helps clinicians predict the risks involved in management and in timely intervention.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
64J Ment Health Policy Econ 2015 Dec 18: 185-200
PMID26729007
TitleCost-effectiveness Analysis of Aripiprazole Once-Monthly for the Treatment of Schizophrenia in the UK.
Abstractschizophrenia is a severe and debilitating psychiatric disorder. Pharmacological interventions aim to ameliorate symptoms and reduce the risk of relapse and costly hospitalisation. Despite the established efficacy of antipsychotic medication, compliance to treatment is poor, particularly with oral formulation. The emergence of long acting injectable (LAI) antipsychotic formulations in recent years has aimed to counteract the poor compliance rates observed and optimise long term patient outcomes.
To estimate the cost-effectiveness of aripiprazole once-monthly 400mg (AOM 400) vs. risperidone long acting injectable (RLAI), paliperidone long acting injectable (PLAI) and olanzapine long acting injectable (OLAI) in the maintenance treatment of chronic, stable schizophrenia patients in the United Kingdom.
A Markov model was developed to emulate the treatment pathway of a hypothetical cohort of patients initiating maintenance treatment with LAI antipsychotics. The economic analysis was conducted from a National Health Service (NHS) and Personal Social Services (PSS) perspective over a 10 year time horizon. Efficacy and safety probabilities were derived from mixed treatment comparisons (MTCs) where possible. Analyses were conducted assuming pooled dosing from randomised clinical trials included in the MTCs.
The model estimates that AOM 400 improves clinical outcomes by reducing relapses per patient comparative to other LAIs over the model time horizon (2.38, 2.53, 2.70, and 2.67 for AOM 400, RLAI, PLAI and OLAI respectively). In the deterministic analysis, AOM 400 dominated PLAI and OLAI; an incremental cost-effectiveness ratio (ICER) of GBP 3,686 per QALY gained was observed against RLAI. Results from the univariate sensitivity analyses highlighted the probability and cost of relapse as main drivers for cost-effectiveness. In the probabilistic sensitivity analysis, AOM 400 demonstrated a marginally higher probability of being cost-effective (51%) than RLAI, PLAI and OLAI (48%, 1% and 0%, respectively) at a willingness to pay threshold of GBP 20,000.
The model was built to accommodate results of an adjusted MTC analysis. Furthermore the model effectively captures repercussions of deteriorating compliance to treatment by incorporating three levels of compliance with elevated risks of relapse for partial compliance and non-compliance. Limitations of the analysis include the limited number of studies incorporated in the MTC, the extrapolation of short term clinical data and the exclusion of the wider societal burden.
Comparative to other atypical antipsychotics, AOM 400 represents value for money in the maintenance treatment of chronic, stable schizophrenia; however, in light of the PSA findings and comparable cost-effectiveness (i.e. against RLAI), the product profile and wider benefits of the respective treatments must be taken into account when prescribing antipsychotics.
Future research should assess the use of LAI antipsychotics earlier in the disease course of schizophrenia to see whether improved compliance and outcomes shortly following the onset of psychosis has the potential to alter the disease trajectory. Moreover it should be assessed whether changes in the disease trajectory can alleviate cost and resource pressures placed on national health services.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
65BMC Health Serv Res 2015 -1 15: 439
PMID26424408
TitleDeterminants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis.
AbstractSerious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems.
We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS.
Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS.
By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
66Lancet Psychiatry 2015 May 2: 395-402
PMID26360283
TitleBespoke smoking cessation for people with severe mental ill health (SCIMITAR): a pilot randomised controlled trial.
AbstractPeople with severe mental ill health are three times more likely to smoke but typically do not access conventional smoking cessation services, contributing to widening health inequalities and reduced life expectancy. We aimed to pilot an intervention targeted at smokers with severe mental ill health and to test methods of recruitment, randomisation, and follow up before implementing a full trial.
The Smoking Cessation Intervention for Severe Mental Ill Health Trial (SCIMITAR) is a pilot randomised controlled trial of a smoking cessation strategy designed specifically for people with severe mental ill health, to be delivered by mental health nurses and consisting of behavioural support and drugs, compared with a conventional smoking cessation service (ie, usual care). Adults (aged 18 years or older) with bipolar disorder or schizophrenia, who were current smokers, were recruited from NHS primary care and mental health settings in the UK (York, Scarborough, Hull, and Manchester). Eligible participants were randomly allocated to either usual care (control group) or usual care plus the bespoke smoking cessation strategy (intervention group). Randomisation was done via a central telephone system, with computer-generated random numbers. We could not mask participants, family doctors, and researchers to the treatment allocation. Our primary outcome was smoking status at 12 months, verified by carbon monoxide measurements or self-report. Only participants who provided an exhaled CO measurement or self-reported their smoking status at 12 months were included in the primary analysis. The trial is registered at ISRCTN.com, number ISRCTN79497236.
Of 97 people recruited to the pilot study, 51 were randomly allocated to the control group and 46 were assigned to the intervention group. Participants engaged well with the bespoke smoking cessation strategy, but no individuals assigned to usual care accessed NHS smoking cessation services. At 12 months, 35 (69%) controls and 33 (72%) people assigned to the intervention group provided a CO measurement or self-reported their smoking status. Smoking cessation was highest among individuals who received the bespoke intervention (12/33 [36%] vs 8/35 [23%]; adjusted odds ratio 2·9, 95% CI 0·8-10·5).
We have shown the feasibility of recruiting and randomising people with severe mental ill health in a trial of this nature. The level of engagement with a bespoke smoking cessation strategy was higher than with a conventional approach. The effectiveness and safety of a smoking cessation programme designed particularly for people with severe mental ill health should be tested in a fully powered randomised controlled trial.
National Institute of Health Research Health Technology Assessment Programme.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
67Lancet Psychiatry 2015 Apr 2: 305-13
PMID26360083
TitleEffects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis.
AbstractWorry might be a contributory causal factor in the occurrence of persecutory delusions in patients with psychotic disorders. Therefore we postulated that reducing worry with cognitive behaviour therapy (CBT) would reduce persecutory delusions.
For our two-arm, assessor-blinded, randomised controlled trial (Worry Intervention Trial [WIT]), we recruited patients aged 18-65 years with persistent persecutory delusions but non-affective psychosis from two centres: the Oxford Health National Health Service (NHS) Foundation Trust (Oxford, UK) and the Southern Health NHS Foundation Trust (Southampton, UK). The key inclusion criteria for participants were a score of at least 3 on the Psychotic Symptoms Rating Scale (PSYRATS) denoting a current persecutory delusion; that the delusion had persisted for at least 3 months; a clinical diagnosis of schizophrenia, schizoaffective disorder, or delusional disorder; and a clinically significant level of worry. We randomly assigned (1:1) eligible patients, using a randomly permuted block procedure with variable block sizes and division by four strata, to either six sessions of worry-reduction CBT intervention done over 8 weeks added to standard care (the CBT-intervention group), or to standard care alone (the control group). The assessors were masked to patient allocations and did their assessments at week 0 (baseline), 8 weeks (end of treatment), and 24 weeks, follow-up. The primary outcomes were worry measured by the Penn State Worry Questionnaire (PSWQ) and delusions measured by the PSYRATS-delusion scale; we did the analyses in the intention-to-treat population, and also did a planned mediation analysis. This trial is registered with the ISRCTN Registry (number ISRCTN23197625) and is closed to new participants.
From Nov 1, 2011, to Sept 9, 2013, we recruited 150 eligible participants and randomly assigned 73 to the CBT intervention group, and 77 to the control group. 143 patients (95%) provided primary outcome follow-up data. Compared with standard care alone, at 8 weeks the CBT intervention significantly reduced worry (mean difference 6·35 [SE 1·56] PSWQ units, 95% CI 3·30-9·40; p<0·001) and persecutory delusions (2·08 [SE 0·73] PSYRATS units, 95% CI 0·64-3·51; p=0·005). The reductions were maintained to 24 weeks follow-up. The mediation analysis suggested that the change in worry accounted for 66% of the change in delusion. No patients died or were admitted to secure units during our study. Six suicide attempts (two in the CBT intervention group, and four in the control group) and two serious violent incidents (one in each group) were noted, but no adverse events were deemed related to the treatments or the assessments.
To our knowledge, this is the first large trial focused on persecutory delusions. We have shown that long-standing delusions were significantly reduced by a brief intervention targeted on worry, although the limitations for our study include no determination of the key elements within the intervention. Our results suggest that worry might cause paranoia, and that worry intervention techniques might be a beneficial addition to the standard treatment of psychosis.
Efficacy and Mechanism Evaluation programme, which is a UK Medical Research Council and National Institute of Health Research partnership.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
68BMJ Open 2015 -1 5: e007619
PMID26346872
TitleNegative symptoms in schizophrenia: a study in a large clinical sample of patients using a novel automated method.
AbstractTo identify negative symptoms in the clinical records of a large sample of patients with schizophrenia using natural language processing and assess their relationship with clinical outcomes.
Observational study using an anonymised electronic health record case register.
South London and Maudsley NHS Trust (SLaM), a large provider of inpatient and community mental healthcare in the UK.
7678 patients with schizophrenia receiving care during 2011.
Hospital admission, readmission and duration of admission.
10 different negative symptoms were ascertained with precision statistics above 0.80. 41% of patients had 2 or more negative symptoms. Negative symptoms were associated with younger age, male gender and single marital status, and with increased likelihood of hospital admission (OR 1.24, 95% CI 1.10 to 1.39), longer duration of admission (?-coefficient 20.5?days, 7.6-33.5), and increased likelihood of readmission following discharge (OR 1.58, 1.28 to 1.95).
Negative symptoms were common and associated with adverse clinical outcomes, consistent with evidence that these symptoms account for much of the disability associated with schizophrenia. Natural language processing provides a means of conducting research in large representative samples of patients, using data recorded during routine clinical practice.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
69BMJ Open 2015 -1 5: e007504
PMID25998036
TitleMood instability is a common feature of mental health disorders and is associated with poor clinical outcomes.
AbstractMood instability is a clinically important phenomenon but has received relatively little research attention. The objective of this study was to assess the impact of mood instability on clinical outcomes in a large sample of people receiving secondary mental healthcare.
Observational study using an anonymised electronic health record case register.
South London and Maudsley NHS Trust (SLaM), a large provider of inpatient and community mental healthcare in the UK.
27,704 adults presenting to SLaM between April 2006 and March 2013 with a psychotic, affective or personality disorder.
The presence of mood instability within 1?month of presentation, identified using natural language processing (NLP).
The number of days spent in hospital, frequency of hospital admission, compulsory hospital admission and prescription of antipsychotics or non-antipsychotic mood stabilisers over a 5-year follow-up period.
Mood instability was documented in 12.1% of people presenting to mental healthcare services. It was most frequently documented in people with bipolar disorder (22.6%), but was common in people with personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (? coefficient 18.5, 95% CI 12.1 to 24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75 to 2.17), greater likelihood of compulsory admission (OR 2.73, 2.34 to 3.19) and an increased likelihood of prescription of antipsychotics (2.03, 1.75 to 2.35) or non-antipsychotic mood stabilisers (2.07, 1.77 to 2.41).
Mood instability occurs in a wide range of mental disorders and is not limited to affective disorders. It is generally associated with relatively poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also suggest that targeted interventions for mood instability may be useful in patients who do not have a formal affective disorder.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
70PLoS ONE 2015 -1 10: e0126530
PMID25992560
TitleDelays before Diagnosis and Initiation of Treatment in Patients Presenting to Mental Health Services with Bipolar Disorder.
AbstractBipolar disorder is a significant cause of morbidity and mortality. Although existing treatments are effective, there is often a substantial delay before diagnosis and treatment initiation. We sought to investigate factors associated with the delay before diagnosis of bipolar disorder and the onset of treatment in secondary mental healthcare.
Retrospective cohort study using anonymised electronic mental health record data from the South London and Maudsley NHS Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register on 1364 adults diagnosed with bipolar disorder between 2007 and 2012. The following predictor variables were analysed in a multivariable Cox regression analysis: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder. The outcomes were time to recorded diagnosis from first presentation to specialist mental health services (the diagnostic delay), and time to the start of appropriate therapy (treatment delay).
The median diagnostic delay was 62 days (interquartile range: 17-243) and median treatment delay was 31 days (4-122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18-3.06) and treatment delay (4.40, 3.63-5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33-0.41) and substance misuse disorders (0.44, 0.31-0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.
Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder after initiation of specialist mental healthcare, particularly those who have prior diagnoses of alcohol and substance misuse disorders. These findings highlight a need for further study on strategies to better identify underlying symptoms and offer appropriate treatment sooner in order to facilitate improved clinical outcomes, such as developing specialist early intervention services to identify and treat people with bipolar disorder.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
71BMC Psychiatry 2015 -1 15: 85
PMID25886265
TitleA randomised controlled trial of positive memory training for the treatment of depression within schizophrenia.
AbstractDepression is highly prevalent within individuals diagnosed with schizophrenia, and is associated with an increased risk of suicide. There are no current evidence based treatments for low mood within this group. The specific targeting of co-morbid conditions within complex mental health problems lends itself to the development of short-term structured interventions which are relatively easy to disseminate within health services. A brief cognitive intervention based on a competitive memory theory of depression, is being evaluated in terms of its effectiveness in reducing depression within this group.
This is a single blind, intention-to-treat, multi-site, randomized controlled trial comparing Positive Memory Training plus Treatment as Usual with Treatment as Usual alone. Participants will be recruited from two NHS Trusts in Southern England. In order to be eligible, participants must have a DSM-V diagnosis of schizophrenia or schizo-affective disorder and exhibit at least a mild level of depression. Following baseline assessment eligible participants will be randomly allocated to either the Positive Memory Training plus Treatment as Usual group or the Treatment as Usual group. Outcome will be assessed at the end of treatment (3-months) and at 6-month and 9-month post randomization by assessors blind to group allocation. The primary outcome will be levels of depression and secondary outcomes will be severity of psychotic symptoms and cost-effectiveness. Semi-structured interviews will be conducted with all participants who are allocated to the treatment group so as to explore the acceptability of the intervention.
Cognitive behaviour therapy is recommended for individuals diagnosed with schizophrenia. However, the number of sessions and length of training required to deliver this intervention has caused a limit in availability. The current trial will evaluate a short-term structured protocol which targets a co-morbid condition often considered of primary importance by service users. If successful the intervention will be an important addition to current initiatives aimed at increasing access to psychological therapies for people diagnosed with severe mental health problems.
Current Controlled Trials. ISRCTN99485756 . Registered 13 March 2014.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
72Eur. Psychiatry 2015 Jan 30: 152-9
PMID25541346
TitleReasons for cannabis use in first-episode psychosis: does strength of endorsement change over 12 months?
AbstractWhy patients with psychosis use cannabis remains debated. The self-medication hypothesis has received some support but other evidence points towards an alleviation of dysphoria model. This study investigated the reasons for cannabis use in first-episode psychosis (FEP) and whether strength in their endorsement changed over time.
FEP inpatients and outpatients at the South London and Maudsley, Oxleas and Sussex NHS Trusts UK, who used cannabis, rated their motives at baseline (n=69), 3 months (n=29) and 12 months (n=36). A random intercept model was used to test the change in strength of endorsement over the 12 months. Paired-sample t-tests assessed the differences in mean scores between the five subscales on the Reasons for Use Scale (enhancement, social motive, coping with unpleasant affect, conformity and acceptance and relief of positive symptoms and side effects), at each time-point.
Time had a significant effect on scores when controlling for reason; average scores on each subscale were higher at baseline than at 3 months and 12 months. At each time-point, patients endorsed 'enhancement' followed by 'coping with unpleasant affect' and 'social motive' more highly for their cannabis use than any other reason. 'Conformity and acceptance' followed closely. 'Relief of positive symptoms and side effects' was the least endorsed motive.
Patients endorsed their reasons for use at 3 months and 12 months less strongly than at baseline. Little support for the self-medication or alleviation of dysphoria models was found. Rather, patients rated 'enhancement' most highly for their cannabis use.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
73Behav Res Ther 2015 Jan 64: 24-30
PMID25499927
TitleOpportunities and challenges in Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI): evaluating the first operational year of the South London and Maudsley (SLaM) demonstration site for psychosis.
AbstractDespite its demonstrated clinical and economic effectiveness, access to Cognitive Behavioural Therapy for psychosis (CBTp) in routine practice remains low. The UK National Health Service (NHS England) Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) initiative aims to address this problem. We report 14-month outcomes for our psychosis demonstration site. Primary and secondary care and self-referrals were screened to check the suitability of the service for the person. Psychotic symptoms, distress, service use, functioning and satisfaction were measured before and after therapy, by trained assessors. User-defined wellbeing and goal-attainment were rated sessionally. Access to CBTp increased almost threefold (2011/12 accepted referrals/year n = 106; 2012/13, n = 300). The IAPT-SMI assessment protocol proved feasible and acceptable to service users, with paired primary outcomes for 97% of closed cases. Therapy completion (?5 sessions) was high (83%) irrespective of ethnicity, age and gender. Preliminary pre-post outcomes showed clinical improvement and reduced service use, with medium/high effect sizes. User-rated satisfaction was high. We conclude that individual psychological interventions for people with psychosis can be successfully delivered in routine services using an IAPT approach. High completion rates for paired outcomes demonstrate good user experience, clinical improvement, and potential future cost savings.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
74J. Psychopharmacol. (Oxford) 2016 May 30: 436-43
PMID26905920
TitleAntipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders.
AbstractAntipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality.
We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting.
Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP.
The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13).
APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
75J. Psychopharmacol. (Oxford) 2016 Apr -1: -1
PMID27097730
TitleFactors associated with changes in hospitalisation in patients prescribed clozapine.
AbstractThe objective of this study was to examine whether delays in clozapine treatment affect outcomes once clozapine is started and identify factors that affect these outcomes.
Patients starting clozapine in a four year period at South London and the Maudsley NHS Foundation Trust were included. Clinical details were gathered from clinical notes. Primary outcome was net change in inpatient admissions comparing the periods before and after clozapine was started.
There was no significant association between the length of clozapine delay (mean clozapine delay = 3.93 years) and number or length of inpatient admissions once clozapine had been started (mean net change in days of admission = 16.74 days), F value = 0.901, p = 0.345. Clozapine reduced the total number of bed days per year, but only if treatment was continued - stopping resulted in inpatient admissions returning to pre-clozapine levels. Younger patients had a greater reduction in bed days when taking clozapine (p = 0.027).
Clozapine reduces the number of inpatient days, regardless of the chronicity of the illness at the time clozapine was started. Continued compliance with clozapine is necessary to maintain this benefit. Reduction in bed days is greater in younger patients, suggesting early initiation of clozapine may be beneficial.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
76BJPsych Bull 2016 Feb 40: 5-11
PMID26958352
TitleMaintaining Adherence Programme: evaluation of an innovative service model.
AbstractAims and method The Maintaining Adherence Programme (MAP) is a new model of care for patients with schizophrenia, schizoaffective disorder and bipolar affective disorder which aims to encourage adherence and prevent relapse. This evaluation, conducted by retrospective and prospective data collection (including patient questionnaires and staff interviews), aimed to describe MAP's impact on healthcare resource use, clinical measures and patient and staff satisfaction, following its implementation in a university National Health Service (NHS) foundation trust in England. We included 143 consenting patients who entered MAP before 31 March 2012. Results In-patient bed days and non-MAP NHS costs reduced significantly in the 18 months post-MAP entry. At 15-18 months post-MAP, Medication Adherence Rating Scale scores had improved significantly from baseline and there was a shift towards less severe clinician-rated disease categories. Based on patient surveys, 96% would recommend MAP to friends, and staff were also overwhelmingly positive about the service. Clinical implications MAP was associated with reduced cost of treatment, improvements in clinical outcomes and very high patient and staff satisfaction.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
77Health Technol Assess 2016 Feb 20: 1-100
PMID26869182
TitleClinical effectiveness and cost-effectiveness of body psychotherapy in the treatment of negative symptoms of schizophrenia: a multicentre randomised controlled trial.
AbstractThe negative symptoms of schizophrenia significantly impact on quality of life and social functioning, and current treatment options are limited. In this study the clinical effectiveness and cost-effectiveness of group body psychotherapy as a treatment for negative symptoms were compared with an active control.
A parallel-arm, multisite randomised controlled trial. Randomisation was conducted independently of the research team, using a 1?:?1 computer-generated sequence. Assessors and statisticians were blinded to treatment allocation. Analysis was conducted following the intention-to-treat principle. In the cost-effectiveness analysis, a health and social care perspective was adopted.

age 18-65 years; diagnosis of schizophrenia with symptoms present at >?6 months; score of ??18 on Positive and Negative Syndrome Scale (PANSS) negative symptoms subscale; no change in medication type in past 6 weeks; willingness to participate; ability to give informed consent; and community outpatient.
inability to participate in the groups and insufficient command of English.
Participants were recruited from NHS mental health community services in five different Trusts. All groups took place in local community spaces.
Control intervention: a 10-week, 90-minute, 20-session group beginners' Pilates class, run by a qualified Pilates instructor. Treatment intervention: a 10-week, 90-minute, 20-session manualised group body psychotherapy group, run by a qualified dance movement psychotherapist.
The primary outcome was the PANSS negative symptoms subscale score at end of treatment. Secondary outcomes included measures of psychopathology, functional, social, service use and treatment satisfaction outcomes, both at treatment end and at 6-month follow-up.
A total of 275 participants were randomised (140 body psychotherapy group, 135 Pilates group). At the end of treatment, 264 participants were assessed (137 body psychotherapy group, 127 Pilates group). The adjusted difference in means of the PANSS negative subscale at the end of treatment was 0.03 [95% confidence interval (CI) -1.11 to 1.17], showing no advantage of the intervention. In the secondary outcomes, the mean difference in the Clinical Assessment Interview for negative symptoms expression subscale at the end of treatment was 0.62 (95% CI -1.23 to 0.00), and in extrapyramidal movement disorder symptoms -0.65 (95% CI -1.13 to -0.16) at the end of treatment and -0.58 (95% CI -1.07 to -0.09) at 6 months' follow-up, showing a small significant advantage of body psychotherapy. No serious adverse events related to the interventions were reported. The total costs of the intervention were comparable with the control, with no clear evidence of cost-effectiveness for either condition.
Owing to the absence of a treatment-as-usual arm, it is difficult to determine whether or not both arms are an improvement over routine care.
In comparison with an active control, group body psychotherapy does not have a clinically relevant beneficial effect in the treatment of patients with negative symptoms of schizophrenia. These findings conflict with the review that led to the current National Institute for Health and Care Excellence guidelines suggesting that arts therapies may be an effective treatment for negative symptoms.
Determining whether or not this lack of effectiveness extends to all types of art therapies would be informative.
Current Controlled Trials ISRCTN842165587.
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. 20, No. 11. See the NIHR Journals Library website for further project information.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
78J Ment Health 2016 Jun 25: 204-11
PMID26472054
TitlePsychological interventions for housebound people with psychosis: service user and therapist perspectives in South East London.
AbstractPeople with psychosis often have difficulty leaving their homes to perform tasks of daily living, which also limits their access to clinic-based interventions to support recovery. Home-based psychological therapy may offer a solution.
To examine service user and therapist perspectives on (i) houseboundness in psychosis and (ii) the value of home-based psychological interventions, as a first step towards a systematic evaluation.
Semistructured interviews with 10 service users and 12 therapists from a large inner city mental health NHS Foundation Trust were thematically analysed.
Houseboundness most commonly resulted from anxiety, paranoia and amotivation, indicating the potential usefulness of targeted psychological therapies. Home-based therapy was offered unsystematically, with variable goals. Although beneficial for engagement and assessment, little gain was reported from undertaking a full course of therapy at home.
Home visits could be offered by psychological therapists to engage and assess housebound service users, but home-based therapy may be best offered on a short-term basis, targeting paranoia, anxiety and amotivation to increase access to other resources. Given the increased cost associated with home-based psychological interventions, a systematic evaluation of their impact is warranted.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
79Clin Drug Investig 2016 Jun 36: 479-90
PMID27000061
TitleCost-Minimisation Analysis of Paliperidone Palmitate Long-Acting Treatment versus Risperidone Long-Acting Treatment for Schizophrenia in Spain.
AbstractLong-acting formulations for paliperidone (PPLAT) and risperidone (RLAT) are effective second-generation antipsychotics. This study aimed to compare treatment costs between PPLAT and RLAT in schizophrenia patients.
A cost-minimization analysis was performed from the perspective of the Spanish National Healthcare System (NHS), in line with the approach accepted by the Scottish Medicine Consortium evaluation. Only direct health costs (?, 2015) were included, i.e. medication (including oral antipsychotic drug supplementation), hospitalization and cost of administration in the community. Two time horizons were used: 1 year (to compare initiation treatment) and 2 years (to compare maintenance treatment). Base-case considered the following assumptions: setting for treatment initiation (50 % hospital and 50 % community); 50 % of patients initiating from a long-acting treatment and 50 % from an oral antipsychotic; no reduction in the length of stay. One-way sensitivity analyses (SA) were performed.
The estimated costs/patient were ?7698 (PPLAT) and ?8168 (RLAT) for the first year, and ?4314 (PPLAT) and ?5003 (RLAT) for the second year. Cost savings related to PPLAT therapy were ?470 and ?689 for first and second year, respectively. SA results confirmed the robustness of the model results, even in the most conservative scenarios: (1) if 100 % of patients initiate treatment in hospital, the savings could be ?454 per patient; (2) if 100 % of patients initiate treatment from an oral antipsychotic, the savings could be ?277 per patient/year; and (3) if PPLAT could not reduce the length of stay by approximately one-third, as some studies indicate, the savings could be ?470 per patient/year.
The use of PPLAT instead of RLAT could be a cost-saving strategy for the Spanish NHS.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
80Trials 2016 -1 17: 134
PMID26969128
TitleThe efficacy of a new translational treatment for persecutory delusions: study protocol for a randomised controlled trial (The Feeling Safe Study).
AbstractPersecutory delusions (strong unfounded fears that others intend harm to the person) occur in more than 70 % of the patients diagnosed with schizophrenia. This major psychotic experience is a key clinical target, for which substantial improvement in treatment is needed. Our aim is to use advances in theoretical understanding to develop a much more efficacious treatment that leads to recovery in at least 50 % of people with persistent persecutory delusions. Our cognitive conceptualisation is that persecutory delusions are threat beliefs, developed in the context of genetic and environmental risk, maintained by a number of psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering the feared situations after reduction of the influence of the maintenance factors. We have been individually evaluating modules targeting causal factors. These will now be tested together as a full treatment, called The Feeling Safe Programme. The treatment is modular, personalised, and includes patient preference. We will test whether the new treatment leads to greater recovery in persistent persecutory delusions, psychological well-being, and activity levels compared to befriending (that is, controlling for therapist attention).
The Feeling Safe Study is a parallel group randomised controlled trial for 150 patients who have persecutory delusions despite previous treatment in mental health services. Patients will be randomised (1:1 ratio) to The Feeling Safe Programme or befriending (both provided in 20 sessions over 6 months). Standard care will continue as usual. Online randomisation will use a permuted blocks algorithm, with randomly varying block size, stratified by therapist. Assessments, by a rater blind to allocation, will be conducted at 0, 6 (post treatment), and 12 months. The primary outcome is the level of delusional conviction at 6 months. Secondary outcomes include levels of psychological well-being, suicidal ideation, and activity. All main analyses will be intention-to-treat. The trial is funded by the NHS National Institute for Health Research.
The Feeling Safe study will provide a Phase II evaluation of a new targeted translational psychological treatment for persecutory delusions.
Current Controlled Trials ISRCTN18705064 (registered 11 November 2015).
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
81Int J Clin Pharm 2016 Apr 38: 344-52
PMID26797771
TitleThe influence of organisational climate on care of patients with schizophrenia: a qualitative analysis of health care professionals' views.
AbstractBackground Organizational climate relates to how employees perceive and describe the characteristics of their employing organization. It has been found to have an impact on healthcare professionals' and patients' experiences of healthcare (e.g. job satisfaction, patient satisfaction), as well as organizational outcomes (e.g. employee productivity). This research used organizational theory to explore dynamics between health care professionals (pharmacists, doctors and nurses) in mental health outpatients' services for patients taking clozapine, and the perceived influence on patient care. Setting Seven clozapine clinics (from one NHS mental health Trust in the UK) which provided care for people with treatment resistant schizophrenia. Methods This study used qualitative methods to identify organizational climate factors such as deep structures, micro-climates and climates of conflict that might inhibit change and affect patient care. Using Interpretative Phenomenological Analysis, semistructured interviews were conducted with 10 healthcare professionals working in the clinics to explore their experiences of working in these clinics and the NHS mental health Trust the clinics were part of. Main outcome measure Health Care Professionals' perceptions of the care of patients with treatment resistant schizophrenia. Results Three superordinate themes emerged from the data: philosophy of care, need for change and role ambiguity. Participants found it difficult to articulate what a philosophy of care was and in spite of expressing the need for change in the way the clinics were run, could not see how 'changing things would work'. There was considerable role ambiguity with some 'blurring of the boundaries between roles'. Factors associated with organizational climate (role conflict; job satisfaction) were inhibiting team working and preventing staff from identifying the patients' health requirements and care delivery through innovation in skill mix. There were mixed attitudes towards the pharmacist's inclusion as a team member. Conclusions Our findings suggest deficiencies within the clinics that may be manifestations of the wider culture of the NHS. The implications for mental health outpatient clinics are that local initiatives are crucial to the implementation of recovery models; clear guidance should be provided on the skill mix required in clozapine clinics and interprofessional learning should be encouraged to reduce role conflict.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal
82J. Psychopharmacol. (Oxford) 2016 May 30: 436-43
PMID26905920
TitleAntipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders.
AbstractAntipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality.
We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting.
Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP.
The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13).
APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.
SCZ Keywordsschizophrenia, schizophrenic, schizophrenics, schizotypal