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Biomedical subjects

P Tyrer

Publications and source records attributed to P Tyrer.

At least 19 recordsLinked to original sources
PubMed2006

Do care patterns change over time in a newly established mental health service? A report from the UK700 trial.

PURPOSE: Data on the process of mental health care is scant. Most studies focus on services at their inception when activity may be atypical and then usually present data only mean values for the reported variables over the whole study period. We aimed to test whether care delivery changes over time, and to describe any changes at the individual patient and team levels. METHODS: Process data on 272 patients in three new intensive case management (ICM) teams were collected over 2 years. Interventions were prospectively recorded using clinician-derived categories. Changes over time are described at both patient and team level. RESULTS: The number of contacts and the proportion of face-to-face activity were remarkably constant after the first month at the patient level. The proportion of 'psychiatric' interventions (main focus on medication or a specific 'mental health' intervention performed) increased greatly after the first 6 months. The care activity received by individual patients varied considerably. Overall, teams varied significantly in the extent to which their activity rates were sustained over time. CONCLUSIONS: New ICM teams deliver highly individualised care with more marked differences in treatment patterns between patients in the same team than mean differences between teams. The early 'engagement' period is marked by a greater focus on social care. There is evidence of differences in sustainability of the services by site.

Adolescent↗
PubMed2005

Temporal reliability of psychological assessments for patients in a special hospital with severe personality disorder: a preliminary note.

BACKGROUND: The new programme for assessing those with dangerous and severe personality disorder relies heavily on psychological assessments of personality disorder and risk. METHODS: The temporal reliability of assessments of psychopathy (PCL-R), risk (HCR-20) and personality was assessed using the International Personality Disorder Examination (IPDE) in 15 randomly selected male prisoners in a high secure hospital carried out at intervals varying between a mean of nine and 19 months after initial assessments by a variety of assessors. RESULTS: Using the intra-class correlation coefficient the agreement varied between 0.57 (HCR-20), 0.58 (PCL-R) and 0.38-0.70 for IPDE personality disorders, with the best agreement for antisocial personality disorder (0.70). COMMENT: These levels of agreement are consistent with other recent work on temporal reliability of personality instruments but are a little too low for confidence in these measures alone in the assessment process.

Adult↗
PubMed2005

Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey.

BACKGROUND: Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England. METHOD: We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16-74 years, living in private households in England. RESULTS: Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups. CONCLUSIONS: Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

Adolescent↗
PubMed2005

Randomized controlled trial of assertive community treatment in intellectual disability: the TACTILD study.

BACKGROUND: There has been a policy shift away from hospital to community in the services of all those with psychiatric disorders, including those with intellectual disability (ID), in the last 50 years. This has been accompanied recently by the growth of assertive outreach services, but these have not been evaluated in ID services. METHOD: In a randomized controlled trial we compared assertive outreach with 'standard' community care, using global assessment of function (GAF) as the primary outcome measure, and burden and quality of life as secondary measures. RESULTS: We recruited 30 patients, considerably less than expected; no significant differences were found between the primary and secondary outcomes in the two groups. The differences were so small that a Type II error was unlikely. CONCLUSIONS: Reasons for this lack of specific efficacy of the assertive approach are discussed and it is suggested that there is a blurring of the differences between standard and assertive approaches in practice.

Adolescent↗
PubMed2005

The Nottingham study of neurotic disorder: predictors of 12 year costs.

OBJECTIVE: To examine the relationship between clinical, demographic and socio-economic characteristics and the long-term costs of a cohort of neurotic patients. METHOD: Analysis of the costs of a cohort of 210 people entered in the Nottingham study of neurotic disorders, a randomized controlled evaluation of five treatments for neurotic disorders. Service use data were collected at 5 and 12 years after study entry. Multiple regression analyses were conducted. RESULTS: The total cost per patient over the 12-year follow-up period was calculated to be $11,940 (SD $15,520) ( pound7450, SD pound9690). Higher costs were significantly associated with the presence of general neurotic syndrome, an initial diagnosis of dysthymia and a recurrent episode of illness. CONCLUSION: The total costs of care for a range of neurotic disorders are broadly comparable with other estimates of costs reported in the literature for similar populations. Those responsible for higher costs in the longer-term have comorbid anxiety, depressive and personality disorders.

Adult↗
PubMed2004

Therapist competence and clinical outcome in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial: the POPMACT study.

BACKGROUND: Therapist competence may be an important factor in determining clinical outcome in psychological therapies. However, there are few published studies of therapist competence v. patient outcome from randomized controlled trials. We tested the hypothesis that higher levels of therapist competence would lead to better clinical outcomes in both patient- and observer-rated measures at 6- and 12-month follow-up. METHOD: A random sample of 49 audiotapes of manual assisted cognitive therapy sessions delivered by 21 therapists involved in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial was rated to assess the level of therapist competence. Patient outcome was assessed using self and observer ratings of depressive and anxiety symptoms, social functioning, global functioning and number of episodes of deliberate self-harm. RESULTS: At 6-month follow-up, there was a statistically significant association between therapist level of competence and observer-rated depression only. At 12-month follow-up, significant associations were noted between therapist competence and all observer-rated clinical outcomes but not for self-rated outcome measures. However, there was no association between therapist competence and the number of self-harm episodes during follow-up. CONCLUSIONS: When treated by therapists rated as more competent than other therapists who received equivalent brief training, patients with recurrent self-harm show significant clinical improvements. However, this benefit is not identified across all outcome measures and is not fully apparent until 12-month follow-up.

Adult↗
PubMed2004

Persistent social dysfunction in anxious and depressed patients with personality disorder.

OBJECTIVE: To determine the long-term social function of psychiatric patients with anxiety and depressive disorders and to relate this to personality status and other factors. METHOD: A cohort of 210 patients (mean age 35 years) with dysthymic disorder, generalized anxiety disorder or panic disorder diagnosed using a structured interview (SCID) were assessed at baseline for personality status using the Personality Assessment Schedule (PAS) and ratings of anxiety and depression. Exactly 12 years later social function was assessed using the Social Functioning Questionnaire (SFQ) and personality reassessed with the PAS by a rater blind to initial personality status. Individual social function items were examined in those with and without personality disorders. RESULTS: Social function was significantly better in those with little or no baseline personality disturbance (P < 0.001) and the domains of close relationships, stress in completing tasks, use of spare time and family relationships showed the largest personality differences. A multiple linear regression model showed that self-rated depression scores, single marital status and personality status were the main baseline variables predicting social function at 12 years. CONCLUSION: Although personality characteristics may change over time social dysfunction persists and persistent social dysfunction in mental state disorders may be a strong indicator of personality disturbance rather than an indicator of treatment resistance.

Adult↗
PubMed2004

Prevalence and service implications of health anxiety in genitourinary medicine clinics.

A comparison of the prevalence of health anxiety in genitourinary medicine (GUM) clinics in two UK centres was carried out using a new rating scale, the Health Anxiety Inventory (HAI). The relationship of health anxiety to demographic and clinical variables, and its impact on service contacts, was also examined in one of these centres. 694 patients were assessed and significant health anxiety was identified in 8-11%. HAI scores were stable over time and high levels persisted in the absence of treatment. Attenders with sexually transmitted infections had significantly lower levels of health anxiety than those with other conditions. Contacts with clinic doctors and health advisors in the nine months before and after assessment were significantly greater in those with high health anxiety, with doctor appointments 37% higher in the high HAI group (P = 0.005). Health anxiety is a source of considerable morbidity in GUM clinics deserving further study.

Adult↗
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

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers.

OBJECTIVE: To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process. METHOD: A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK). RESULTS: Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI. CONCLUSION: While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

Cross-Sectional Studies↗
PubMed2003

Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis?

OBJECTIVE: To examine the association between co-morbid personality disorder (PD) and suicidal behaviour over a 2-year period in a sample of patients with psychosis. METHOD: A total of 670 patients with established psychotic illness were interviewed using a battery of instruments including a screen for co-morbid PD. The prevalence of attempted and completed suicide was measured over the next 2 years using multiple data sources. Logistic regression was used to examine whether those with co-morbid PD were at greater risk of suicidal behaviour compared with others. RESULTS: One hundred and eighty six patients (28%) were rated as having a co-morbid PD. After adjusting for all covariates, patients with co-morbid PD were significantly more likely to attempt or complete suicide over the 2-year period (adjusted odds ratio: 1.87; 95% CI: 1.02-3.42). CONCLUSION: Co-morbid PD is independently associated with an increased risk of suicidal behaviour in psychosis. Early assessment of personality status should be part of the routine assessment of all psychiatric patients.

Adult↗
PubMed2003

"Cold calling" in psychiatric follow up studies: is it justified?

BACKGROUND: The ethics of cold calling-visiting subjects at home without prior appointment agreed-in follow up research studies has received little attention although it is perceived to be quite common. We examined the ethical implications of cold calling in a study of subjects with defined neurotic disorders followed up 12 years after initial assessment carried out to determine outcome in terms of symptoms, social functioning, and contact with health services. The patients concerned were asked at original assessment if they would agree to be followed up subsequently and although they agreed no time limit was put on this. OBJECTIVES: To decide if cold calling was ethically justifiable and, if so, to set guidelines for researchers. DESIGN: The study was a cohort study of patients with neurotic disorder treated initially for 10 weeks in a randomised controlled trial. FINDINGS: At follow up by a research medical practitioner 18 of the 210 patients had died and of the remaining 192 patients 186 (97%) were seen or had a telephone interview. Four patients refused and two others did not have interviews but agreed to some data being obtained. However, only 104 patients (54%) responded to letters inviting them to make an appointment or to refuse contact and the remainder were followed up by cold calling, with most patients agreeing readily to the research interview. The findings illustrate the dilemma of the need to get the maximum possible data from such studies to achieve scientific validity (and thereby justify the ethics of the study) and the protection of subjects' privacy and autonomy. CONCLUSIONS: More attention needs to be paid to consent procedures if cold calling is to be defended on ethical grounds but it is unreasonable to expect this to be obtained at the beginning of a research study in a way that satisfies the requirements for informed consent. A suggested way forward is to obtain written consent for the research at the time that cold calling takes place before beginning the research.

Adult↗
PubMed2003

Comorbidity of substance misuse and mental illness in community mental health and substance misuse services.

BACKGROUND: Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management. AIMS: To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management. METHOD: Cross-sectional prevalence survey in four urban UK centres. RESULTS: Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention. CONCLUSIONS: Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

Adult↗
PubMed2002

A randomised controlled trial of enhanced key-worker liaison psychiatry in general practice.

BACKGROUND: Despite much interest in the development of liaison psychiatry in general practice there is no clear evidence that any form of intervention is effective. We carried out a pilot randomised controlled trial, the first we believe into this type of care, of one such model; enhanced liaison with individual patients by key workers, in general practices in Paddington and North Kensington in London. METHODS: All patients referred from primary to secondary psychiatric care from four general practices over a 10-month period, and still in contact with services, were eligible to be included in the study. The practices were allocated in a constrained randomised procedure to either normal care or enhanced key-worker liaison. The latter involved encouraging individual key workers to adopt improved communication between primary and secondary care. Baseline assessments of symptomatology and social functioning were made before randomisation and after 6 months by an independent researcher. RESULTS: Of the 84 eligible patients, 43 were seen at baseline and 34 re-assessed after 6 months. There was no difference between the clinical outcomes in the two groups but self-rated social function was significantly improved in the enhanced liaison service compared with standard care (adjusted P = 0.05). Costs were similar but somewhat more expensive for enhanced liaison. Less than half (42 %) of all key workers in the enhanced liaison arm felt they had involved the primary health care team more in the care of their patient, with 21 % of these altering their practice markedly during the study. CONCLUSIONS: It is concluded that without additional resources enhanced key-worker liaison for psychiatry in primary and secondary care has limited benefits although this does not necessarily apply to other forms of liaison practice.

Adult↗
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

The measurement of engagement in the homeless mentally ill: the Homeless Engagement and Acceptance Scale--HEAS.

BACKGROUND: Much of the difficulty in helping the homeless mentally ill arises as a consequence of their resistance to engagement. A refused intervention can seldom influence a client's problems and engagement status can be argued as being an important independent predictor of outcome. No instrument could be identified which systematically measured the factors involved. This paper describes the development and psychometric properties of a new scale, the Homeless Engagement and Acceptance Scale (HEAS). METHOD: Staff from an established project for the homeless mentally ill helped to identify relevant questions used to develop a five-item rating scale for completion by an informant. After piloting, the instrument was tested in a study in which subjects were assessed twice over 12 months by informants. Item analysis was undertaken and predictive validity was assessed. RESULTS: Item analysis indicated a good facility index signifying all items were able to differentiate subjects according to the characteristic being measured, and a high discrimination index demonstrating that all items were measuring the same concept. Predictive validity and internal consistency coefficients were both good. The 3 month HEAS score was found to be a significant predictor of accommodation status and adequacy of a support network at 12 months. CONCLUSIONS: The good psychometric properties and predictive validity of the scale suggest the HEAS is likely to be a useful tool in assessing engagement status. One of the five questions (Q4) can be omitted for those who are not homeless and the scale termed the Engagement and Acceptance Scale (EAS).

Defense Mechanisms↗