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Biomedical subjects

P Lelliott

Publications and source records attributed to P Lelliott.

18 recordsLinked to original sources
PubMed1998

Protocol for assessing services for people with severe mental illness.

BACKGROUND: The Clinical Standards Advisory Group was asked by UK health ministers to advise on the standards of clinical care being achieved for people with schizophrenia. A subcommittee commissioned a review of standards, followed by research into how far these were reflected in contracts and met by providers. METHOD: No comprehensive but practical set of standards was found. A protocol of 143 items of good service practice was constructed, and applied by teams visiting services in II UK districts. The team appraisals were summarised in 20 key points, each scored 0 (absent) to 4 (excellent performance). Seven points were used to assess standards of commissioning and 13 for standards of service provision. RESULTS: When placed into rank order, the mean key point scores for commissioners and providers in the same district tended to be very similar. Total district scores were then used to assign districts to one of three groups. Four performed reasonably well, five were moderate and two were poor. CONCLUSIONS: One of the key elements associated with these differences was the local level of morale. After wide consultation, a revised protocol of 26 key points for direct rating was drawn up and has since been further tested.

Clinical Protocols↗
PubMed1998

Junior doctors' training in the theory and the practice of electroconvulsive therapy.

Recent advances in knowledge about effective administration of electroconvulsive therapy (ECT) has placed great emphasis on the importance of good training and supervision of those administering it. The American Psychiatric Association requires that doctors be specifically accredited before they are allowed to give ECT. In England and Wales training is much more informal and ECT is often given by junior doctors. Doctors rostered to administer ECT in Wales and in two areas of England were surveyed as part of the College's third audit of ECT. About two-thirds of respondents were at senior house officer level. The training in ECT appeared of variable quality and one-half had not been supervised by an experienced psychiatrist on the first occasion they administered ECT. Responses to exam-type questions revealed that 45% lacked knowledge about one or more basic issue related to effective administration of ECT.

Education, Medical, Continuing↗
PubMed1997

The cost consequences of changing the hospital-community balance: the mental health residential care study.

BACKGROUND: Altering the balance of provision between hospital and community care is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could be supported more appropriately elsewhere, in turn denying in-patient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure. METHODS: Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of today's balance of care were explored. Comprehensive costs were calculated and their associations with resident characteristics examined using multiple regression analyses. RESULTS: On a like-with-like basis, the costs of hospital in-patient treatment for inappropriately placed patients greatly exceeded the costs of community-based care. CONCLUSION: Further reduction of hospital beds, however, is not the panacea for an appropriate balance of mental health care, given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous in-patient bed reductions apparent in the services surveyed. Rather, service providers and purchasers should focus on developing community-based care (including increased provision of 24-hour nursed beds) by ensuring that resources released through earlier closure programmes have been redeployed for their intended use and by accessing additional pump-priming or bridging resources.

Chronic Disease↗
PubMed1997

The mental health residential care study: predicting costs from resident characteristics.

BACKGROUND: Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary. METHOD: As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs. RESULTS: Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts. CONCLUSIONS: The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.

Adolescent↗
PubMed1996

The mental health residential care study: classification of facilities and description of residents.

BACKGROUND: The NHS is no longer a virtual monopoly provider of mental health residential care. This makes it difficult to assess the volume, range and adequacy of local provision. METHOD: Local data collectors used standard instruments to collect detailed information about 368 facilities (with 1951 residents) providing mental health residential care in eight districts. Because local definitions were inconsistent, facilities were reclassified on the basis of facility size and extent of day and night cover. The eight categories of accommodation are compared on levels of staffing, staff qualifications and the characteristics of their residents. RESULTS: There was a nearly threefold variation between districts in the total number of residential places available per unit of population, and even greater variation in the number of places with 24-hour waking cover. Most residents have long-term, severe mental illness and severe impairment. Long-stay wards accommodate people who pose greater risk of violence than do the two types of non-hospital facility with 24-hour waking cover (P < 0.001). The former also employ a much greater proportion of staff with formal care qualifications and, in particular, nursing qualifications than the latter (49% v. 15%, P < 0.001). CONCLUSIONS: It is suggested that one consequence of the diversification in provision of mental health residential accommodation has been a relative reduction in the proportion of provision available to the most severely disabled. This might apply particularly to those who pose a risk of acting violently.

Aged↗
PubMed1994

A national audit of new long-stay psychiatric patients. I: Method and description of the cohort.

BACKGROUND: This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort. METHOD: Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18-64 on admission, who had been in hospital for between six months and three years. RESULTS: Two particular sub-groups were observed. Younger NLS patients (aged 18-34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55-67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm. CONCLUSIONS: Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.

Adolescent↗
PubMed1994

A national audit of new long-stay psychiatric patients. II: Impact on services.

BACKGROUND: This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital. METHOD: Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements. RESULTS: The average point prevalence was 6.1 per 100,000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100,000 population per year. Many English services had very few non-acute psychiatric beds and 31% of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61% of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available. CONCLUSIONS: Many NLS patients remain in hospital because their residential needs are not met by existing community provision.

Adolescent↗
PubMed1993

Who pays for community care? The same old question.

Trends in mental health service funding over the past 40 years show that the programme of hospital closures has not resulted in a significant release of resources to fund community based services. Far from being excessive, the current provision of residential services (both NHS and non-NHS) for mentally ill people is now below levels recommended as sufficient by the government, the Royal College of Psychiatrists, and the National Schizophrenia Fellowship. What clinical research evidence there is suggests that more rather than fewer residential places are required. This situation is likely to be compounded by the recent transfer of responsibility for funding private and voluntary residential care from the Department of Social Security to local authority social services departments.

Community Mental Health Services↗
PubMed1991

Six-year follow-up after exposure and clomipramine therapy for obsessive compulsive disorder.

To determine whether gains from exposure therapy are lasting in patients with chronic obsessive compulsive disorder, the authors followed up 34 (85%) of 40 such patients who had been treated 6 years earlier with exposure therapy for 3 or 6 weeks and with clomipramine or placebo for 36 weeks. Severity of obsessive compulsive disorder was assessed by rating the discomfort caused by the time devoted to four target rituals, the Behavioral Avoidance Test, and the Compulsion Checklist. Mood was assessed by the 17-item Hamilton Rating Scale for Depression, the Wakefield Self-Assessment Depression Inventory, and the Anxiety scale. In addition, the patients' general adjustment was assessed. The authors found that the group as a whole remained significantly improved on obsessive compulsive symptoms, work and social adjustment, and depression; however, the group returned to pretreatment levels (slight to moderate) of general anxiety. They found that neither clomipramine nor placebo affected long-term outcome and that the majority of patients who were taking clomipramine or other antidepressants at follow-up were no more improved that those who were not taking antidepressants. Better long-term outcome correlated with more exposure therapy (6 weeks of therapy vs. 3 weeks) and with better compliance with the exposure therapy homework. The best predictor of long-term outcome was improvement at the end of treatment. Subjects who had initially been most depressed were more likely to receive psychotropic medication during follow-up. Initial severity of illness did not preclude benefit from exposure therapy.

Antidepressive Agents, Tricyclic↗
PubMed1990

Symptom specificity in patients with panic.

Thirteen patients with panic disorder with predominantly cardiorespiratory (CR) symptoms were compared with seven patients with predominantly gastrointestinal (GI) symptoms in an experimental procedure that involved exposure to phobia talk and voluntary hyperventilation (VHV). The CR patients had not only higher baseline anxiety, but also during phobia talk had a greater fall in pCO2 and reported more respiratory symptoms than the GI patients. Moreover, the CR group found VHV more unpleasant and more like their panic attacks than the GI panickers, and reported more physical symptoms after it. These findings suggest that patients with PD are not only heterogeneous with respect to the system to which panic symptoms refer (Cr or GI) but that provoking arousal in one system is more likely to produce distress if that system is the major focus of complaint. These findings, if replicated, would not support the suggestion that panic disorder is a uniform illness.

Adult↗
PubMed1989

Onset of panic disorder with agoraphobia. Toward an integrated model.

Of 57 patients with panic disorder with agoraphobia, more had their first panic in late spring and summer than in fall and winter, and in warm weather than in cold weather. In the month before the first panic 52% of the patients had prodromal depression or anxiety. Agoraphobic avoidance preceded the first panic in 23%, began within days after the first panic in 32% (without prodromal anxiety or depression in only 20%), and after more than one panic (1 week to 11 years later) in 41%. The site of the first panic was from the agoraphobic cluster (public places) in 81%, at work or school in 11%, and inside the home in 8%. Thirty-eight percent of patients were with a familiar adult at the time. Many features of the syndrome can be explained by an integrated model with several interacting factors contributing in varying degrees to the different routes by which it develops. To the learning and biological factors already suggested we add an evolutionary factor to explain why most first panics occur outside the home and mainly in public places. Certain extraterritorial cues constituting an agoraphobic cluster seem to be prepotent and prepared triggers or modifiers of fear during stress.

Agoraphobia↗
PubMed1989

Fear talk versus voluntary hyperventilation in agoraphobics and normals: a controlled study.

Twenty-three drug-free patients with agoraphobia and panic disorder (DSM-III criteria) had, at rest, lower mean end-tidal PCO2 (32 v. 36 mmHg) and higher mean heart rate (92 v. 83 bpm) than did 18 controls. During 5 min of listening to fear talk, only eight (35%) patients and three (16%) controls panicked, but panic was associated with marked physiological changes in only two patients and one control. Patients said that breathlessness began slightly more often before than after panic. In 59% of patients the symptoms from voluntary hyperventilation (VHV) were very similar or identical to those of their usual panics. Compared with the remainder, these patients felt more unpleasant during hyperventilation (HV); in such patients HV may aggravate somatic symptoms. Agoraphobics with panic differed from controls in having higher baseline arousal, but were not more reactive than controls to HV or fear talk.

Agoraphobia↗
PubMed1988

Urinary cortisol during exposure in obsessive-compulsive ritualizers.

Nineteen obsessive-compulsive (OC) ritualizers were exposed to both brief and prolonged neutral and aversive stimuli (the latter evoked a significant urge to ritualize). Urinary cortisol and subjective anxiety were measured over 3 1/2 hours throughout the experiment, and cortisol secretion was compared to a control session the previous day. Both groups showed higher cortisol secretion after exposure compared to the control session. Only the group that received prolonged aversive stimuli, in addition to brief aversive and neutral stimuli, showed significantly higher urinary cortisol levels after the session. Cortisol response correlated with subjective anxiety reports during prolonged aversive stimulation only.

Adolescent↗
PubMed1988

Clomipramine, self-exposure and therapist-aided exposure for obsessive-compulsive rituals.

A randomised treatment design for 49 chronically obsessive-compulsive ritualising patients was devised and three controlled comparisons were made. 1. During 7 weeks of self-exposure instructions, clomipramine treatment improved some measures of rituals and depression significantly more than did placebo medication; this effect was transient and disappeared as drug treatment and exposure were continued for a further 15 weeks. 2. During 11-16 weeks of clomipramine treatment, self-exposure instructions yielded highly significantly more patient improvement than did anti-exposure instructions on nearly all measures of rituals and some of social adjustment. 3. Adding therapist-aided exposure (1.3 hours) to self-exposure instructions (3 hours) after 8 weeks had a barely significant transient effect of dubious clinical value, which was lost by the end of exposure (at week 23) and during follow-up assessments to week 52. We conclude that of the three therapeutic factors tested, self-exposure was the most potent; clomipramine played a limited adjuvant role, and therapist-aided exposure a marginal one.

Adolescent↗