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Biomedical subjects

M Knapp

Publications and source records attributed to M Knapp.

At least 37 records · Page 2Linked to original sources
PubMed2003

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study.

BACKGROUND: We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm. METHOD: Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months. RESULTS: Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20). CONCLUSION: Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Adult↗
PubMed2003

Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach.

BACKGROUND: Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death. METHOD: Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves. RESULTS: Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive. CONCLUSION: Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.

Adult↗
PubMed2003

Financing health care in Europe: context for the Schizophrenia Outpatient Health Outcomes Study.

OBJECTIVE: Exploration of the implications for mental health care of the health care funding environment in Europe, as context for the Schizophrenia Outpatient Health Outcomes (SOHO) Study. METHOD: Data on health care financing for individual countries were sourced by review of the literature and personal communication with European country representatives. RESULTS: The main and complementary sources of health care finance are presented for the 10 European countries participating in the SOHO study. CONCLUSION: A mixture of tax and social insurance funding mechanisms dominate general health care funding in Europe. These mechanisms in principle promote equity in access to all health care interventions, including those for mental health. However, current resource allocation to mental health care may not reflect fully the impact of mental health disorders. Further work is now under way to examine the contribution of non-health sectors (such as social welfare) to the funding and provision of services.

Ambulatory Care↗
PubMed2003

Unit costs in international economic evaluations: resource costing of the Schizophrenia Outpatient Health Outcomes Study.

OBJECTIVE: We present unit costs corresponding to resource information collected in the Schizophrenia Outpatient Health Outcomes (SOHO) Study. METHOD: The SOHO study is a 3-year, prospective, observational study of health outcomes associated with antipsychotic treatment in out-patients treated for schizophrenia. The study is being conducted across 10 European countries (Denmark, France, Germany, Greece, Ireland, Italy, the Netherlands, Portugal, Spain and the UK) and includes over 10,800 patients and over 1000 investigators. To identify the best available unit costs of hospital admissions, day care and psychiatrist out-patient visits, a tariff-based approach was used. RESULTS: Unit costs were obtained for nine of the 10 countries and were adjusted to 2000 price levels by consumer price indices and converted to US dollars using purchasing power parity rates (and on to Euro). CONCLUSION: The paper illustrates the need to balance the search for sound unit costs with pragmatic solutions in the costing of international economic evaluations.

Ambulatory Care↗
PubMed2003

The European Schizophrenia Outpatient Health Outcomes (SOHO) study: rationale, methods and recruitment.

OBJECTIVE: The objective of the European Schizophrenia Outpatient Health Outcomes (SOHO) study is to understand the comparative costs and outcomes of antipsychotic drug treatment, with specific focus on olanzapine. The study will also provide a large database for research into the treatment and outcome of schizophrenia. The role of observational studies in the assessment of the effectiveness of antipsychotic agents is reviewed, and the rationale, design and recruitment issues surrounding the SOHO study are presented. METHOD: SOHO is a 3-year, prospective, observational study of the health outcomes associated with antipsychotic treatment in Europe. RESULTS: Over 10 000 patients have been recruited from 10 countries. Baseline evaluation included measures of clinical status, social functioning, quality of life, service use and pharmacological treatment. Patients will be followed for 3 years. CONCLUSION: The SOHO study will complement randomized controlled trial findings on the treatment of schizophrenia and will address relevant clinical and policy research questions.

Activities of Daily Living↗
PubMed2002

Provision of services for people with schizophrenia in five European regions.

BACKGROUND: An increasing diversity of public, voluntary sector and private providers offer services for the mentally ill in the ongoing process of psychiatric reform. Good service description is one important prerequisite for mental health service research. Aims 1) To describe service provision for the mentally ill in five European centres using the European Service Mapping Schedule (ESMS); and 2) to discuss the use of the instrument in describing service provision. METHODS: All services providing care for people with severe mental illness in five European catchment areas (in Amsterdam, the Netherlands; Copenhagen, Denmark; London, UK; Santander, Spain; Verona, Italy) were identified through various sources. The identified services were classified, and service provision was quantified in accordance with the ESMS manual. Descriptive information was obtained. RESULTS: We identified from 10 to 45 different services for catchment areas of between 50,000 (Copenhagen) and 560,000 (Santander) population run by three to 16 providers. They varied in aims, staffing and functioning. Hospital and non-hospital residential services, community-based services, and social support agencies were available in all sites. There was substantial variation across centres in the range, number and activities of services. Collecting comparable data sets on all service types, particularly for day and structured activity services and outpatient and community services required substantial effort. CONCLUSION: Operationalised description of mental health services across Europe is possible but requires further refinement.

Adolescent↗
PubMed2002

Accurate power approximations for chi2-tests in case-control association studies of complex disease genes.

A popular method for the analysis of case-control association studies is to compare the frequencies of the alleles between cases and controls by means of Pearson's chi2-statistic. Here, an approach for computing the power of this test is presented, which by computer simulation is shown to be more reliable than a previously published power approximation. Since the test based on Pearson's chi2- statistic can be anti-conservative if there is an excess of homozygotes for the susceptibility allele in the general population, it has been proposed to analyze case-control association studies by means of a trend test based on genotypes instead of alleles. We present an accurate power approximation for the trend test. The power approximations are implemented in an available computer program 'GenOdyPower', which in addition has an option to determine the empirical power of these tests by simulations.

Algorithms↗
PubMed2002

Home treatment for mental health problems: a systematic review.

BACKGROUND: Concerns have been raised about the scope and generalizability of much community mental health research. In particular, both experimental and control services are poorly characterized. METHODS: To review the effectiveness of 'home treatment' for mental health problems in terms of hospitalization, we conducted a systematic review, using Cochrane methodology but with a wider remit. Non-randomized studies were included in response to concerns about RCTs' generalizability. All authors were followed up for data on service components. 'Home treatment' was defined broadly for the purposes of the literature search, but included studies were then assessed against service components specifically focused on delivering treatment at home. The study tested components and other features for associations with days in hospital, as well as conducting a conventional meta-analysis of data on days in hospital. RESULTS: We found 91 studies, 18 comparing home to in-patient treatment. Sixty per cent of authors responded to follow-up. The vast majority of the services studied had a 'home treatment function' and regularly visited patients at home. The heterogeneity of control services made meta-analysis problematical as did the limited availability of data. There was some evidence that 'regular' home visiting and combined responsibility for health and social care were associated with reduced hospitalization. The inclusion of non-randomized studies rarely affected the findings. CONCLUSIONS: Evidence concerning the effectiveness of home treatment remains inconclusive. A centrally coordinated research strategy is recommended, with attention to study design. Experimental and control service components should be prospectively recorded and reported to enable meaningful analysis.

Community Mental Health Services↗
PubMed2002

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough.

BACKGROUND: Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group. METHODS: The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years. RESULTS: Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups. CONCLUSIONS: Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.

Adolescent↗
PubMed2002

Costs of village community, residential campus and dispersed housing provision for people with intellectual disability.

BACKGROUND: In recent years, a growing volume of research evidence has been generated about the relative cost-effectiveness of various types of community-based residential supports for people with intellectual disability (ID) in the UK. However, few reliable data are available to inform planners, commissioners or service providers about the quality and costs of providing support within residential or village communities. METHODS: The evaluation described in the present paper aimed to fill some of the gaps in knowledge by examining the comparative costs of supporting people in village community settings, in National Health Service (NHS) residential campuses and in dispersed, community-based housing schemes. The complete service package received by each study participant was described and costed, and a series of statistical analyses was undertaken to identify factors associated with variations in the cost of support. The analyses reported in the present paper were based on comparisons of 86 people living in village communities, 133 in residential campuses and 281 in dispersed housing schemes. RESULTS: Wide variations in cost were found, not only between models of accommodation, but between individual organizations, settings and service users. Multivariate analysis revealed that higher costs were associated with supports for people with higher levels of ID and more severe challenging behaviour. The cost of support was affected by the size of the residential setting, with smaller facilities likely to be more expensive. Associations were also found between increased costs, and services for younger users, male users and people who had not moved from a NHS hospital. Generally, more sophisticated service processes within the setting were associated with higher costs; although systematic arrangements for supervision and training of staff had a negative effect on cost. CONCLUSIONS: The cost findings should be considered alongside evidence on outcomes. A comparison of village communities and dispersed housing schemes suggests that both models of provision appear be associated with particular benefits, although different types of setting are appropriate for different individuals and therefore, the continued development of a range of residential models is important.

Adult↗
PubMed2002

Depot antipsychotic preparations in schizophrenia: the state of the economic evidence.

Depot treatment of schizophrenia - to date restricted to conventional antipsychotic medications - remains widespread. Whilst there have been numerous studies of clinical effectiveness, and systematic reviews of the accumulated evidence, little appears to be known about the cost-effectiveness of depot treatment. A systematic review was conducted of the international literature in an attempt to find, appraise and summarize the economic evaluative evidence. Very few studies of relevance or quality could be found. Most of the papers purporting to examine the economic consequences of depot treatment were methodologically weak. There were no randomized controlled trials of depot vs. oral antipsychotics, the few mirror-image studies were uncontrolled and a single naturalistic observational study measured costs only narrowly. Two modelling studies - which have a number of limitations because of their partial reliance on expert opinion rather than observational data - suggest that depot treatment may lower costs and improve cost-effectiveness. Overall, however, it is not possible to draw conclusions as to the cost-effectiveness of depot conventional antipsychotic treatment for schizophrenia.

Antipsychotic Agents↗
PubMed2002

International differences in home treatment for mental health problems. Results of a systematic review.

BACKGROUND: It is perceived that North American home treatment studies reveal greater success in reducing days in hospital than do European studies. There are difficulties in extrapolating findings internationally. AIMS: We aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital. METHOD: The results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted. RESULTS: Most of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations. CONCLUSIONS: North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.

Community Mental Health Services↗
PubMed2001

Financial cost of social exclusion: follow up study of antisocial children into adulthood.

OBJECTIVES: To compare the cumulative costs of public services used through to adulthood by individuals with three levels of antisocial behaviour in childhood. DESIGN: Costs applied to data of 10 year old children from the inner London longitudinal study selectively followed up to adulthood. SETTING: Inner London borough. PARTICIPANTS: 142 individuals divided into three groups in childhood: no problems, conduct problems, and conduct disorder. MAIN OUTCOME MEASURES: Costs in 1998 prices for public services (excluding private, voluntary agency, indirect, and personal costs) used over and above basic universal provision. RESULTS: By age 28, costs for individuals with conduct disorder were 10.0 times higher than for those with no problems (95% confidence interval of bootstrap ratio 3.6 to 20.9) and 3.5 times higher than for those with conduct problems (1.7 to 6.2). Mean individual total costs were 70 019 pounds sterling for the conduct disorder group (bootstrap mean difference from no problem group 62 pound sterling; 898 pound sterling 22 692 pound sterling to 117 pound sterling) and 24 324 pound sterling (16 707 pound sterling; 6594 pound sterling to 28 149 pound sterling) for the conduct problem group, compared with 7423 pound sterling for the no problem group. In all groups crime incurred the greatest cost, followed by extra educational provision, foster and residential care, and state benefits; health costs were smaller. Parental social class had a relatively small effect on antisocial behaviour, and although substantial independent contributions came from being male, having a low reading age, and attending more than two primary schools, conduct disorder still predicted the greatest cost. CONCLUSIONS: Antisocial behaviour in childhood is a major predictor of how much an individual will cost society. The cost is large and falls on many agencies, yet few agencies contribute to prevention, which could be cost effective.

Child↗
PubMed2001

Association analysis of the functional monoamine oxidase A gene promoter polymorphism in psychiatric disorders.

Functional characterization studies revealed that transcriptional activity of the human monoamine oxidase A (MAOA) gene is modulated by a polymorphic repetitive sequence located approximately 1.2 kb upstream of the ATG codon. To investigate the possible influence of the allelic variants of the MAOA gene-linked polymorphic region (MAOA-LPR) on the genetic predisposition to psychiatric disorders, we have performed a case-control association study. 174 patients with affective disorders and 258 patients with schizophrenia according to DSM-IV, as well as 229 population controls were tested. Statistical analysis showed no significant differences in allele or genotype frequencies between control and patient groups. Our results suggest that there is no association between MAOA-LPR genotype and susceptibility to recurrent major depression, bipolar disorder, and schizophrenia in our population.

Adult↗
PubMed2001

The human dopamine transporter gene: the 5'-flanking region reveals five diallelic polymorphic sites in a Caucasian population sample.

The 5'-flanking region of the human dopamine transporter (hDAT) was systematically screened for variants by single strand conformation analysis (SSCA) between -1586 and +97 basepair (bp) relative to the transcription start site. Five diallelic polymorphisms were found, which were shown to be due to single base substitutions: T-67A, G-660C, C-839T, C-1169G, T-1476G. In a population sample of 119 unrelated Caucasians, allele frequencies of the rarer allele were 47% for -67T, 3% for -660C, 45% for -839T, 50% for -1169G, and 8% for -1476G, respectively. Among 15 observed haplotypes, seven haplotypes collected a frequency of about 96% in our sample. T-67A, C-839T, C-1169G, T-1476G were related to potential transcriptional recognition sites. These findings and the occurrence of distinct haplotypes at the hDAT promoter locus in a Caucasian population sample make this region a promising target in the context of linkage and association studies in certain diseases.

5' Untranslated Regions↗
PubMed2001

Nonreplication of association between mu-opioid-receptor gene (OPRM1) A118G polymorphism and substance dependence.

In the present investigation we hypothesized the A118G (Asn40Asp) polymorphism of the mu-opioid receptor gene (OPRM1) as a particular vulnerability factor for heroin and alcohol dependence. Therefore, we tested this hypothesis in two independent large samples by two different methods: a case-control sample (comprising n = 287 heroin and n = 221 alcohol study subjects versus n = 365 nondependent controls) and a family-controlled sample of 111 parent-offspring trios of heroin-dependent study subjects and 75 parent-offspring trios of alcohol-dependent study subjects to avoid stratification artifacts. In both patient samples and by both methods we were unable to corroborate the hypothesis of OPRM1 A118G polymorphism as a particular risk factor for any kind of substance dependence including opioid addiction. In addition, there was no significant association between the endophenotype of the individuals under study (e.g., comorbidity, severity of illness) and a particular genotype of OPRM1.

Adenine↗
PubMed2001

Structural phase transitions in CaC2.

Pure CaC2, free of CaO impurities, was obtained by the reaction of elemental calcium with graphite at 1,070 K. By means of laboratory X-ray and synchrotron powder diffraction experiments, the phase diagram was investigated in the temperature range from 10 K to 823 K; this confirmed the literature data that reported the partial coexistence of up to four modifications. Aside from a cubic high-temperature modification CaC2 IV (Fm3m, Z = 4) and the well-known tetragonal modification CaC2 I (I4/mmm, Z = 2), a low-temperature modification CaC2 II (C2/c, Z =4) that crystallizes in the ThC2 structure type and a metastable modification CaC2 III (C2/m, Z = 4) that crystallizes in a new structure type were found. It was shown that phase transition temperatures as well as the relative amounts of the various CaC2 modifications depend upon the size of the crystallites, the thermal treatment. and the purity of the sample, as a comparison with technical CaC2 confirmed.

Journal Article↗