Anti-retroviral therapy, insulin resistance and lipodystrophy.
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Animals↗
Biomedical subjects
D Chisholm
Publications and source records attributed to D Chisholm.
Global "burden of disease"-study for psychiatric disorders.
The Global Burden of Disease (GBD) study was conducted to provide a set of summary health measures that would be comprehensive and make available information on disease and injury, including non-fatal health outcomes. The main objective of the GBD approach was to inform global priority setting for health research and to influence international health policy and planning. One of the summary measures used was the Disability Adjusted Life Year (DALY). DALYs are a common metric for fatal and non-fatal health outcomes and are based on years of life lost because of premature death (YLL) and years of life lived with disability (YLD). Thus DALYs = YLL + YLD or Burden = Mortality + Disability. Therefore, a DALY is one lost year of healthy life. The DALY methodology provides a way to link information on disease burden to cost-effectiveness analysis. This feature would assist comparative assessments. The WHO plans to refine this framework for assessing the outcomes of interventions and their related costs.
Cost of Illness↗
Genotyping by microdevice electrophoresis.
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DNA↗
Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy.
BACKGROUND: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue. AIM: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue. DESIGN OF STUDY: A randomised controlled trial incorporating a cost-consequences analysis. SETTING: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months. METHOD: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale. RESULTS: Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score). CONCLUSIONS: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.
Adolescent↗
Integration of mental health care into primary care. Demonstration cost-outcome study in India and Pakistan.
BACKGROUND: Targeting resources on cost-effective care strategies is important for the global mental health burden. AIMS: To demonstrate cost-outcome methods in the evaluation of mental health care programmes in low-income countries. METHOD: Four rural populations were screened for psychiatric morbidity. Individuals with a diagnosed common mental disorder were invited to seek treatment, and assessed prospectively on symptoms, disability, quality of life and resource use. RESULTS: Between 12% and 39% of the four screened populations had a diagnosable common mental disorder. In three of the four localities there were improvements over time in symptoms, disability and quality of life, while total economic costs were reduced. CONCLUSION: Economic analysis of mental health care in low-income countries is feasible and practicable. Our assessment of the cost-effectiveness of integrating mental health into primary care was confounded by the naturalistic study design and the low proportion of subjects using government primary health care services.
Adult↗
The London Depression Intervention Trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs.
BACKGROUND: Relapse of depression is associated with a criticising attitude of the patient's partner. AIMS: To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner. METHOD: A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner. RESULTS: Drop-outs were 56.8% [corrected] from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments. CONCLUSIONS: For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.
Adult↗
Expenditure on mental health care by English health authorities: a potential cause of inequity.
BACKGROUND: The York resource allocation formula includes a calculation of the amount needed to purchase mental health services equitably in each health authority in England. However, the amount which is actually spent on services is at the discretion of the authority. AIMS: To compare expenditure on mental health services with allocation, and test the hypothesis that differences between them are to the disadvantage of services in deprived areas. METHOD: A comparison of routine expenditure and allocation data, and linear regression modelling of the ratio of expenditure to allocation. RESULTS: The ratio of expenditure to allocation varies widely. Relative underspending occurs more frequently in deprived areas, although not in the four inner-London health authorities. CONCLUSIONS: The intentions of the York formula are not achieved in practice. The implications of the formula for mental health should be made explicit to health authorities, and shortfalls in mental health expenditure relative to allocation should be justified at a local level.
Costs and Cost Analysis↗
Client Socio-Demographic and Service Receipt Inventory--European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs.
BACKGROUND: Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required. AIMS: To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care. METHOD: Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods. RESULTS: Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory--European Version (CSSRI-EU). This was subsequently administered to 404 people with schizophrenia across five countries. CONCLUSION: The CSSRI-EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.
Adult↗
Translation and cross-cultural adaptation of outcome measurements for schizophrenia. EPSILON Study 2. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs.
BACKGROUND: Research on the comparison of mental health services has identified the need for internationally standardised and reliable measurements. AIMS: To describe the strategies adopted in the European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study for the translation and cross-cultural adaptation of five European versions of the instruments. METHOD: A protocol was developed for translation of the outcome scales, describing each step in the translation procedure. Disputed items were discussed in focus groups, which faced seven tasks: a list of topics to be discussed; choosing where the group should meet; composition of participants; conducting the group; data collection; data completion afterwards; reporting results. RESULTS: Modifications made to instruments were: changes in the instrument structure, contents and concepts; adjustments to the instrument structure; and modifications to the instrument manual. CONCLUSION: Use of focus groups is an adequate method to apply if concepts, constructs and translation issues are to be addressed; otherwise, less time-consuming methods should be considered.
Cross-Cultural Comparison↗
Two-color multiplexed analysis of eight short tandem repeat loci with an electrophoretic microdevice.
Single-channel microfabricated electrophoretic devices equipped with a dual-wavelength laser-induced fluorescence detection system were used for the fast analysis of an eight-loci, two-color multiplex short tandem repeat (STR) system for human identification. Routine analyses of the eight loci (CSF1PO, TPOX, TH01, vWA and D16S539, D7S820, D13S317, D5S818), requiring four-base resolution, were performed in only 2 min. Specific analyses for a microvariant allele (allele 9.3 of the TH01 locus) demanded single-base resolution and was performed in less than 10 min. The high accuracy of the microdevice for real-world STR sample analyses was demonstrated by comparison with conventional slab-gel electrophoresis. Our results show that a fast multiwavelength multichannel electrophoretic microsystem will be capable of routinely processing thousands of complex STR samples per day.
Color↗
Toward real-world sequencing by microdevice electrophoresis.
We report results using a microdevice for DNA sequencing using samples from chromosome 17, obtained from the Whitehead Institute Center for Genome Research (WICGR) production line. The device had an effective separation distance of 11.5 cm and a lithographically defined injection width of 150 microm. The four-color raw data were processed, base-called by the sequencing software Trout, and compared to the corresponding ABI 377 sequence from WICGR. With a criteria of 99% accuracy, we achieved average continuous reads of 505 bases in 27 min with 3% linear polyacrylamide (LPA) at 150 V/cm, and 460 bases in 22 min with 4% LPA at 200 V/cm at a temperature of 45 degrees C. In the best case, up to 565 bases could be base-called with the same accuracy in <25 min. In some instances, Trout allowed for accurate base-calling down to a resolution R as low as R = 0.35. This may be due in part to the high signal-to-noise ratio of the microdevice. Unlike many results reported on capillary machines, no additional sample cleanup other than ethanol precipitation was required. In addition, DNA fragment biasing (i.e., discrimination against larger fragments) was reduced significantly through the unique sample injection mechanism of the microfabricated device. This led to increased signal strength for long fragments, which is of great importance for the high performance of the microdevice.
Base Sequence↗
Does a hostel's managing agency determine the access to psychiatric services of its residents?
This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff, knowledge of services, which influence access to and use of community services.
Adult↗
Public, private and voluntary residential mental health care: is there a cost difference?
OBJECTIVES: To determine how public (NHS or local government), private (for-profit) and voluntary (non-profit) providers of residential mental health care compare. Do they support different clienteles? And do their services cost different amounts? METHODS: Based on a cross-sectional survey of residential care facilities and their residents in eight English and Welsh localities, the characteristics and costs of care in the different sectors (NHS, local government, private, voluntary) were compared. Variations in cost were examined in relation to residents' characteristics using multiple regression analyses, which also allowed standardisation of results before making inter-sectoral comparisons. RESULTS: Private and voluntary providers of residential care support different clienteles from the public sector. The patterns of inter-sectoral cost differences vary between London and non-London localities. In London, voluntary sector facilities may be more cost-efficient than the other sectors, but local government/private sector comparisons show no consistent difference. Outside London, the results suggest clear cost advantages for the private and voluntary sectors over the local government sector. CONCLUSIONS: Private and voluntary providers may have some economic advantages over their public counterparts. However, outcomes for residents were not studied, leaving unanswered the question of comparative cost-effectiveness.
Community Mental Health Services↗
London-east Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. III: Follow-up and economic evaluation at 18 months.
BACKGROUND: A randomised controlled trial of cognitive-behavioural therapy (CBT) for people with medication-resistant psychosis showed improvements in overall symptomatology after nine months of treatment; good outcome was strongly predicted by a measure of cognitive flexibility concerning delusions. The present paper presents a follow-up evaluation 18 months after baseline. METHOD: Forty-seven (78% of original n = 60) participants were available for follow-up at 18 months, and were reassessed on all the original outcome measures (see Part I). An economic evaluation was also completed. RESULTS: Those in the CBT treatment group showed a significant and continuing improvement in Brief Psychiatric Rating Scale scores, whereas the control group did not change from baseline. Delusional distress and the frequency of hallucinations were also significantly reduced in the CBT group. The costs of CBT appear to have been offset by reductions in service utilisation and associated costs during follow-up. CONCLUSIONS: Improvement in overall symptoms was maintained in the CBT group 18 months after baseline and nine months after intensive therapy was completed. CBT may be a specific and cost-effective intervention in medication-resistant psychosis.
Adult↗
The metabolically obese, normal-weight individual revisited.
Nearly 20 years ago, it was suggested that individuals exist who are not obese on the basis of height and weight, but who, like people with overt obesity, are hyperinsulinemic, insulin-resistant, and predisposed to type 2 diabetes, hypertriglyceridemia, and premature coronary heart disease. Since then it has become increasingly clear that such metabolically obese, normal-weight (MONW) individuals are very common in the general population and that they probably represent one end of the spectrum of people with the insulin resistance syndrome. Available evidence also suggests that MONW individuals could account for the higher prevalence of type 2 diabetes, cardiovascular disease, and other disorders in people with a BMI in the 20-27 kg/m2 range who have gained modest amounts of weight (2-10 kg of adipose mass) in adult life. Specific factors that appear to predispose MONW, as well as more obese individuals, to insulin resistance include central fat distribution, inactivity, and a low VO2max. Because these factors are potentially reversible and because insulin resistance may contribute to the pathogenesis of many diseases, it is our premise that a compelling argument can be made for identifying MONW individuals and treating them with diet, exercise, and possibly pharmacological agents before these diseases become overt, or at least early after their onset. One reason for doing so is that disorders such as type 2 diabetes may be accompanied by irreversible consequences, e.g., ischemic heart disease and nephropathy, at the time of diagnosis or shortly thereafter. Another is that MONW individuals in general should be younger and more amenable and responsive to diet and exercise therapy than are obese patients with established disease. That long-term diet and exercise can work is suggested by two large studies in which, over 5-6 years, the incidence of diabetes was diminished in nonobese and minimally obese patients with impaired glucose tolerance. Based on these considerations and the emerging worldwide epidemic of type 2 diabetes, we believe that studies to assess whether therapies aimed at young MONW individuals can prevent the development of type 2 diabetes and other diseases, including perhaps obesity itself, are urgently needed.
Adult↗
All fired up--receptacle testing rule sparks debate.
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Electric Wiring↗
QALYs and mental health care.
Quality-adjusted life year measures (QALYs) have been fervently debated by researchers and decision makers concerned with resource allocation in the health care sector. They have been heralded as important aids to planning and priority setting, but also criticised on technical and ethical grounds. This paper examines these arguments with special reference to mental health care, the intention being to highlight the strengths and shortcomings of QALYs in this context. Issues pertinent to the application of QALYs in health care evaluation more generally are also reviewed. Whilst the rationale and underlying principles of the utility measurement approach are sound, the generic QALY as it is currently constructed represents an insensitive measure of the outcomes of mental health care. In the event of an increasingly QALY-driven priority-setting environment, however, abandonment of QALYs runs the risk of inappropriately marginalising people with mental illnesses in the resource allocation process. This opens up the possibility of developing a mental-health specific measure of utility that, in combination with cost data, would provide useful and appropriate summary information across treatments and programmes of mental health care.
Cost-Benefit Analysis↗
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↗