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Jeremy Holmes

Publications and source records attributed to Jeremy Holmes.

12 recordsLinked to original sources
PubMed2006

Six-year follow-up of three treatment programs to personality disorder.

Previous studies of long-term outcome for personality disorder (PD) were either retrospective in design or did not include a control condition. In this paper we report results for three PD cohorts (N = 111) treated in two different specialist psychosocial programs (step-down and long-term inpatient) and in general psychiatric treatment as usual (TAU), which were prospectively followed up for 72-months after intake. The three PD samples were compared on symptom severity, social adjustment, global functioning and other clinical indicators (self-mutilation, parasuicide and readmission rates) at intake, 6, 12, 24, and 72 months. Results indicated that a specialist step-down model showed significantly greater change than a purely inpatient model and TAU in most key dimensions of functioning, a difference maintained at 72-months follow-up. Improvement in the samples was not associated with amount of intercurrent treatment received in the year prior to the follow-up assessment. This study confirms that a step-down program retains significant improvement associated with a specialist psychosocial approach for PD. However, this conclusion should be qualified by design limitations. The samples were not randomly allocated to the three conditions and the naturalistic geographical allocation used in the study created a potential for a number of confounds. Whilst we used extensive statistical controls, the possibility that the differences found between the groups may be due to population differences cannot be discounted.

Adult↗
PubMed2005

The cost-effectiveness of human papillomavirus screening for cervical cancer. A review of recent modelling studies.

We compared findings from recent studies modelling the cost-effectiveness of screening for cervical cancer using human papillomavirus (HPV) testing and alternative strategies. Data were standardized to facilitate comparison of costs per life year or costs per QALY gained in six studies. Absolute changes in costs, life years and QALYs for each strategy were normalized to a comparison with no screening. Costs were standardized to US$ in 2000 values. Most models assume screening starts at age 18 or 20 years. Assumed prevalence of HPV ranges from 10% for those aged 18 years to 20% for those aged 20-25 years and drops substantially after age 30. All except one model assume sensitivity to LSIL of 83% or higher. Two models distinguish the increasing specificity of HPV testing in older age groups (up to 95% for LSIL in women aged 55 years or older). All the models include consultation costs as well as screening and treatment costs, but costs for follow-up diagnosis and treatment vary considerably. Two models also include patient time costs. Despite these differences all strategies involving HPV testing have cost per quality-adjusted life-year (QALY) ratios in the range of USD 12,400-16,600. Costs per life year vary more widely, the highest being USD 19,246 (annual screening with liquid cytology and HPV). However, excluding strategies using liquid cytology, the highest costs per life year for a strategy including HPV testing are under USD 14,000 (simultaneous conventional cytology and HPV every two years). The cost per life year for HPV testing alone triennially is lower than for Pap smear testing alone biennially. Costs per QALY are generally lower than costs per life year (given the reported modelling assumptions and settings). Even with inclusion of patient costs, no strategies involving HPV testing cost more than USD 16,600 per QALY. Adoption of the ACOG guidelines to include HPV testing with cytology as a screening option for women aged 30 years or older therefore appears to be cost-effective.

Age Factors↗
PubMed2004

Disorganized attachment and borderline personality disorder: a clinical perspective.

The aim of this paper is to explore the links between the attachment-theory derived concept of disorganized attachment, and the psychiatric diagnosis of Borderline Personality Disorder (BPD). Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with care givers is similarly seen in terms of approach-avoidance dilemmas, which manifests themselves in disturbed transference/countertransference interactions between therapists and BPD sufferers. Possible ways of handling these phenomena are suggested, based on notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.

Borderline Personality Disorder↗
PubMed2004

Residential versus community treatment of personality disorders: a comparative study of three treatment programs.

OBJECTIVE: The aim of this study was to compare the effectiveness of three treatment models for personality disorder: 1) a long-term psychoanalytically oriented residential specialist program, 2) a phased "step-down" specialist psychosocial program that included a briefer residential stay and an outpatient component, and 3) a general community psychiatric model. METHOD: One hundred forty-three patients with a personality disorder diagnosis were allocated according to geographical criteria to the three treatment conditions. Outcome was prospectively evaluated at 6, 12, and 24 months through the use of a standardized battery of instruments that included measures of general symptom severity, social adaptation, assessment of mental health functioning, frequency of self-harm and suicide attempts, and rates and duration of hospital readmissions. RESULTS: By 24 months, patients in the step-down condition showed significant improvements on all measures. Patients in the long-term residential model showed significant improvements in symptom severity, social adaptation, and global functioning, while no changes were achieved in self-harm, attempted suicide, and readmission rates. Patients in the general psychiatric group showed no improvement on any variables except self-harm and hospital readmissions. CONCLUSIONS: The results of this study suggest that for personality disorders, a specialist step-down program is more effective than both long-term residential treatment and general psychiatric treatment in the community. Replication is needed that includes a random allocation of patients to conditions to ensure that geographical factors did not account for the observed differences.

Adult↗
PubMed2004

A cost-effectiveness analysis of docetaxel in the second-line treatment of non-small cell lung cancer.

BACKGROUND: Whilst lung cancer is the most common form of cancer in England and Wales (annual incidence rate of 50 per 100,000) it does not always receive the policy attention accorded to other types of cancer, such as breast and colorectal. Nevertheless, the burden of lung cancer is significant and the UK NHS Plan for cancer has set out the government's commitment to improving all cancer services. The question faced by the NHS is which interventions are most cost effective in implementing this plan. OBJECTIVE: To develop a model to assess the economics of second-line treatment of non-small cell lung cancer (NSCLC) from the perspective of the UK NHS, based on the resources and outcomes from the pivotal clinical study comparing docetaxel 75 mg/m(2) with best supportive care (BSC). METHODS: The area under the survival curve for each treatment was analysed and the difference in mean survival between the docetaxel group and the BSC group was calculated as 3.82 months. Measurable incremental costs for the docetaxel group were largely driven by drug acquisition and administration. These cost drivers, as well as toxicity treatment costs and cost offsets, were varied in the sensitivity analysis. Although the overall timeframe for the model was 2 years, discounting was not applied as the resources and benefits of docetaxel use in this setting are realised relatively immediately. RESULTS: The base case cost-effectiveness analysis (mean values) reported a cost per life-year gained of 13,863 pounds sterling for docetaxel 75 mg/m(2) (year 2000/2001 values). Sensitivity analysis showed that the number of treatment cycles per patient, which affected total treatment cost, had most influence on the cost per life-year gained in the base case scenario. Using the 95% confidence intervals around the mean number of treatment cycles, the base case cost per life-year gained varied from 10,985 pounds sterling to 16,738 pounds sterling. Using the 95% confidence intervals around the mean difference in survival, to represent best and worst case scenarios, the cost per life-year saved ranged from 10,020 pounds sterling to 32,781 pounds sterling . CONCLUSION: This model suggests, with its underlying assumptions and data, docetaxel 75 mg/m(2) in 3-weekly cycles is a cost-effective second-line treatment, from the perspective of the NHS, for pretreated NSCLC in terms of survival gains made for a reasonable increase in costs.

Antineoplastic Agents, Phytogenic↗
PubMed2003

Direct economic impact of Parkinson's disease: a research survey in the United Kingdom.

The direct costs of care were evaluated prospectively in a sample of people with Parkinson's disease (PD) in the United Kingdom in 1998. The subjects were drawn from a random sample of general practitioner practices within a representative sample of 36 Regional Health Authorities and the equivalent. A total of 444 resource use questionnaires with usable data were returned (response rate, 59%). The total mean annual cost of care per patient for all patients by age was 5,993 pounds (9,554 euro, n = 432). Hoehn and Yahr stage significantly (P < 0.001) influenced expenditure by stage as follows: 0 and I, 2,971 pounds (4,736 euro, n = 110); II, pound 3,065 (4,886 euro, n = 89); III, 6,183 pounds (9,857 euro, n = 120); IV, 10,134 pounds (euro;16,155, n = 87); V, 18,358 pounds (29,265 euro, n = 17). National Health Service costs accounted for approximately 38% and social services for 34% of the direct costs of care. Drug expenditure accounted for 24% of overall costs in the <65 years age group and 10% in patients aged >85 years. A move from home to residential care was associated with an approximately 500% cost increase. In conclusion, PD imposes significant direct costs on public services and on individuals. These costs should be taken into account when allocating public funds.

Aged↗
PubMed2003

Do people with type 2 diabetes and their carers lose income? (T2ARDIS-4).

T(2)ARDIS is a study of the full costs of care for a sample of people with type 2 diabetes in the UK. This paper reports on individual earnings lost by patients (n=653) and carers (n=253) aged <65 years, based on 1998 values. Mean annual lost earnings are calculated on three different bases. Across the total survey population aged <65 years, mean lost earnings are estimated at pound 869 (S.D. pound 4109) per patient and pound 1300 (S.D. pound 4093) per carer. However, for the sub-set of respondents who actually lose earnings, the mean levels are pound 13841 (S.D. pound 9551) and pound 10960 (S.D. pound 6002), respectively. Patients and carers who lose earnings incur higher personal care-related expenditure than those who do not lose earnings (although for the patients this is not statistically significant). Patients who lose earnings also report poorer health-related quality of life and carers who lose earnings report higher levels of strain. Only one third of carers report receiving state benefits, and for both carers and patients the shortfall between reported benefits received and lost earnings is substantial. A strong association was found between patients' loss of earnings and the presence of diabetic complications (P<0.001), especially micro-vascular complications. Policy priorities should, therefore, include facilitating comprehensive access to state benefits (especially for carers) and a clear focus on reducing the incidence of diabetic complications.

Adult↗
PubMed2003

Borderline personality disorder and the search for meaning: an attachment perspective.

OBJECTIVE: To explore the links between the attachment theory-derived concept of disorganized attachment, and the psychiatric diagnosis of borderline personality disorder (BPD). METHOD: Literature search for characteristics of disorganized attachment. Clinical case material from psychotherapeutic work with patients suffering from BPD. RESULTS: Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with caregivers is similarly seen in terms of an approach-avoidance dilemma, which manifests itself in disturbed transference/countertransference interactions between therapists and BPD sufferers. Borderline personality disorder sufferers lack meaning in their lives because they are unable to play 'language games' with their potential intimates, resorting to actions rather than words to express feelings. CONCLUSIONS: Possible ways of handling these phenomena are suggested, based on Main's (1995) notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.

Borderline Personality Disorder↗
PubMed2003

When less is more: An exploration of psychoanalytically oriented hospital-based treatment for severe personality disorder.

This paper discusses the main findings of a prospective study based at the Cassel Hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The results--showing that significantly greater improvements on a number of outcome indicators were found in patients exposed to the psychoanalytically informed treatment programmes compared to a general psychiatric approach based on management and pharmacotherapy alone--underscores the importance and the centrality of the psychoanalytic input in the treatment of severe personality disorders. However, the results of the study also suggested that some features of long-term hospital treatment might carry the risk of iatrogenic and anti-therapeutic effects for a sub-group of patients with severe borderline core pathology. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioning of borderline patients.

Adult↗
PubMed2002

Health service use costs by personality disorder following specialist and nonspecialist treatment: a comparative study.

The impact of specialist psychosocial treatment on health service use costs by patients with personality disorder is not yet sufficiently documented. In this prospective study we compare patterns of health service costs by three groups of people with personality disorder treated in a hospital-based program (IPP), a step down program (SDP), and a general psychiatric program (GPP). Total service use costs at follow up, compared with intake costs, showed that significantly higher savings were achieved by SDP and IIP compared with GPP. Cost reductions in SDP were significantly greater than in IPP. Significant cost reductions were found between treatment programs in social worker and community psychiatric nursing and psychotherapy. The cost-effectiveness of the two specialist treatment programs was indicated by the significant association between total cost reduction and clinical outcome in GPP and IPP, but not in GPP. The effect of Major Depression and Borderline Personality Disorder on health service use alone and in combination was also investigated. The finding that Major Depression was found to be more significantly associated with higher health service use costs than Borderline Personality Disorder is discussed.

Adult↗