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Biomedical subjects

M Muijen

Publications and source records attributed to M Muijen.

18 recordsLinked to original sources
PubMed2001

Maintaining contact with people with severe mental illness: 5-year follow-up of assertive outreach.

BACKGROUND: Assertive outreach is a central strand of Government mental health policy in England. Are different long-term models of mental health care which include assertive outreach associated with different service user outcomes and cost? METHOD: We conducted a multi-site 5-year follow-up study of people with severe mental illness. From 0 to 18 months all three sites had Intensive Case Management (ICM) teams practising assertive outreach. From 18 to 60 months one team sustained ICM, one team merged and another was disbanded. All 131 original ICM team clients were the study participants. Outcome was measured in terms of sustained engagement with statutory mental health services, psychiatric symptoms, social functioning, resource use and cost. RESULTS: All 120 live participants were traced. Only four people had no service contact; when contacted by a researcher they appeared to be coping well. No incidents of serious violence were discovered. No differences existed between teams in the mean total symptom or total social functioning change scores at follow-up, after controlling for baseline differences. No differences existed in mean cost between teams during the first 18 months. Mean (standard deviation) annualised costs varied considerably in the 18-60 month period: sustained team Pound Sterling13,734 (10,820); integrated team Pound Sterling11,037 (13,603); disbanded team Pound Sterling5,742 (7,007) (F=4.4, 105 df, p=0.015). CONCLUSION: Continued specialist assertive outreach service models have higher costs than non-specialist services for no apparent benefit. In the long term new assertive outreach services should have procedures in place to transfer people to lower intensity and lower cost care.

Case Management↗
PubMed1998

One day survey by the Mental Health Act Commission of acute adult psychiatric inpatient wards in England and Wales.

OBJECTIVES: To provide (via the Mental Health Act Commission's "national visit") empirical evidence on ward occupancy levels, use of the Mental Health Act 1983, nurse staffing, and care of female patients on acute adult psychiatric wards. DESIGN: One day survey of a stratified random sample. SETTINGS: 119/250 (47%) acute adult psychiatric inpatient units in England and Wales. SUBJECTS: End sample of 263 acute psychiatric inpatient wards. MAIN OUTCOME MEASURES: Ward occupancy rates; number of patients detained under the Mental Health Act and proportion "absent without leave"; nurse staffing levels, skill mix, and vacancies;proportion of women with self contained, women-only facilities. RESULTS: Mean ward occupancy was 99% (95% confidence interval 97% to 102%). A ward mean of 30% (28% to 32%) of patients were detained under the Mental Health Act; of all detained patients, 1% (1% to 2%) were absent without leave. A ward mean of 0.3 (0.29 to 0.31) nurses were on duty per patient at the time of the visit. An estimated ward mean of 31% (30% to 32%) of nurse staffing may have been through casual contracts--higher in inner (48% (43% to 53%)) and outer London (45% (41% to 48%)). On 26% (21% to 32%) of wards, there were no nurses interacting with patients. A ward mean of 36% (30% to 41%) of female patients had self contained, women-only facilities. CONCLUSIONS: Attention should focus on improving the quality of acute inpatient psychiatric care as well as of community care.

Adolescent↗
PubMed1997

Relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units, and alternative residential options: a cross sectional survey, one day census data, and staff interviews.

OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.

Acute Disease↗
PubMed1996

Effects of mental health services reform on clinical practice in the United Kingdom.

In the last few years, the British National Health Service, local government social services departments, the welfare benefits system, and the organization of primary health care in the United Kingdom have undergone major reforms that have had significant effects on mental health services. Local social service departments were given the lead role in purchasing and coordinating community supports for persons with mental illness, but were not given enough funds to arrange adequate services. In the National Health Service, an internal-market approach, in which local health authorities could contract with any provider or group of providers, was introduced. This purchaser-provider split has created a climate of competition in a traditionally collaborative environment and has reduced staff morale. Similar but separate case management models were introduced in both the health service and the social service departments, which has led to inefficiency in planning care for individual patients. Opportunities were created for general practitioners to use capitated funds to purchase specialty care directly from providers. This arrangement resulted in an initial emphasis on care for less severely mentally ill patients, although some general practitioners are beginning to explore new approaches for supporting severely ill patients in the community. On the positive side, the reforms have led to greater involvement of patients and their families in planning service delivery. However, the authors suggest that policy makers in the U.K. seem to be repeating many of the mistakes made by American mental health systems in the 1960s and 1970s.

Cost-Benefit Analysis↗
PubMed1996

Residential care in hospital and in the community--quality of care and quality of life.

BACKGROUND: The reduction of beds in long-stay hospitals has led to concerns over the quality of care offered to the remaining residents as well as that provided in the community. This study seeks to compare the quality of care and quality of life (reported satisfaction) from residents in both types of setting. METHOD: A cross-sectional comparison was made of community residential homes and hospital wards drawn randomly from lists provided by local authorities in the outer London area. Samples were drawn from all the main provider types (local authority, housing association, private and joint NHS/voluntary sector). Measures were taken of the quality of the physical environment, staff and resident characteristics, external management arrangements and internal management regimes, resident satisfaction and staff stress. Direct observations were also made of the amount and quality of staff-resident interactions. RESULTS: In general, the most disabled residents were found to be still living in hospital in the Worst conditions and receiving the poorest quality of care. Although there were some problems with missing data, hospital residents also seemed most dissatisfied with their living situation. There were few differences between community providers regarding either the quality of care provided or the levels of reported satisfaction. Quality of care in the community homes seemed to be much more determined by the personality and orientation of project leaders. CONCLUSIONS: Purchasers and providers still need to give attention to the problems of selectively discharging the most able residents to the community, leaving the most disabled being looked after in progressively deteriorating conditions. All residential providers need to review their internal management practices and try to ensure that residents are offered, as far as possible, the opportunity to make basic choices about where and how they will live. Staff training and quality assurance practices need to be reviewed in order to improve the direct quality of care offered to the most disabled individuals.

Activities of Daily Living↗
PubMed1994

Home-based versus hospital-based care for people with serious mental illness.

BACKGROUND: A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London. METHOD: Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction. RESULTS: Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.) CONCLUSIONS: It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

Activities of Daily Living↗
PubMed1994

Service use and costs of home-based versus hospital-based care for people with serious mental illness.

BACKGROUND: The Daily Living Programme (DLP) offered problem-oriented, home-based care for people aged 17-64 with severe mental illness facing emergency admission to the Bethlem-Maudsley Hospital. The multidisciplinary DLP team acted as direct provider and link with other services. Each patient had a key worker. Cost-effectiveness was assessed. METHOD: The comprehensive costs of DLP and standard in-patient care were compared within a randomised controlled trial. Cost measures ranged over all service inputs and living expenses. The costs of informal care and lost employment were also considered. Assessments of service use, costs and outcomes were conducted at referral, 4, 11 and 20 months. RESULTS: The DLP was significantly less costly than standard treatment in both short and medium term (P = 0.000). Cost savings accrued almost exclusively to the NHS, with no other agency's costs being higher. CONCLUSIONS: Coupled with mildly encouraging outcome results over the 20 month period, the DLP was clearly cost-effective in this medium term.

Absenteeism↗
PubMed1994

Community psychiatric nurse teams: intensive support versus generic care.

BACKGROUND: This study evaluated whether a community psychiatric nurse (CPN) team providing a comprehensive aftercare service, using a case management approach, improves psychopathology and social functioning of the long-term mentally ill, and reduces hospital use compared with a generic CPN team. METHOD: Patients suffering from severe and persistent mental health problems were randomised to intensive aftercare or generic care after referral to the CPN manager. Each group contained 41 patients who were assessed at baseline and at 6, 12 and 18 months by an independent research psychologist. Outcome measures included the GAS, PSE, SAS, patient and relatives' satisfaction, number of admissions, and length of stay. RESULTS: No difference between the groups was found on any of the outcome measures, despite the much higher number of contacts of the intensive (n = 52) versus generic CPNs (n = 13) and the much greater range of interventions. CONCLUSIONS: Intensive aftercare for people with persistent mental health problems was not found to be of greater benefit than generic CPN care. Many factors need to be considered for aftercare to be effective, including community resources, process of care, and staff training.

Activities of Daily Living↗
PubMed1992

Home based care and standard hospital care for patients with severe mental illness: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of home based care with standard hospital care in treating serious mental illness. DESIGN: Randomised controlled trial. SETTING: South Southwark, London. PATIENTS: 189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months' follow up 68 home care and 60 hospital patients were evaluated. MAIN OUTCOME MEASURES: Use of hospital beds, psychiatric diagnosis, social functioning, patients' and relatives' satisfaction, and activity of daily living programme staff. RESULTS: Home care reduced hospital stay by 80% (median stay six days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval -1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme. CONCLUSIONS: Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required.

Adult↗
PubMed1992

The daily living programme. Preliminary comparison of community versus hospital-based treatment for the seriously mentally ill facing emergency admission.

Patients with a serious mental illness requiring admission were randomised to home care or standard hospital care. Over the initial 18 months, 60 patients entered each group and were studied for a mean of 10 months. Home care reduced hospital use by 80%, with patients being admitted for a mean of 14 days, compared with 72 days for the standard group, but this bed-saving made no difference in direct treatment costs. Home care offers individualised treatment, and many patients require continuing support with the emphasis on areas such as finances and housing.

Activities of Daily Living↗
PubMed1988

A comparative clinical trial of fluoxetine, mianserin and placebo in depressed outpatients.

Fluoxetine, a selective serotonin reuptake inhibitor, was compared with mianserin and placebo in a double-blind study. In total, 81 depressed patients were included. Patients were rated weekly on the Hamilton Depression Rating Scale (HDRS) and the Montgomery & Asberg Depression Rating Scale (MADRS). The duration was 6 weeks, and 52 patients completed the study. Significantly more patients on fluoxetine improved than patients on placebo. For mianserin no significant differences were found with either fluoxetine or placebo. Mean HDRS at the end of the study was also statistically significantly lower for fluoxetine, but not for mianserin, than placebo. Subscores of the MADRS showed improved sleep on mianserin at weeks 2 and 3. Suicidal feelings were reduced to a greater degree on fluoxetine than on mianserin and placebo at weeks 6 and 7. Fluoxetine induced weight loss, while patients on mianserin gained weight. Side effects were present in most patients on the two active drugs; those on fluoxetine experienced nausea and vomiting, and those on mianserin drowsiness.

Adolescent↗
PubMed1987

A comparative hospital survey of psychotropic drug prescribing.

In a survey of psychotropic drug prescribing for in-patients in three different types of psychiatric hospitals, the prevalence of combinations of more than one psychotropic drug varied from 45% in one hospital to 94% in another, with significant consistent differences between the use of drug combinations in the various hospitals. Combinations of two antipsychotic drugs were particularly frequent; the hospital with the lowest prevalence of polypharmacy was the only one with an associated psychopharmacology unit. Access to clinical pharmacology teaching may be an important factor in determining appropriate drug-prescribing habits.

Adolescent↗