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Biomedical subjects

Graham Thornicroft

Publications and source records attributed to Graham Thornicroft.

At least 19 recordsLinked to original sources
PubMed2006

Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial.

OBJECTIVE: To investigate the cost effectiveness of joint crisis plans, a form of advance agreement for people with severe mental illness. DESIGN: Single blind randomised controlled trial. SETTING: Eight community mental health teams in southern England. PARTICIPANTS: 160 people with a diagnosis of psychotic illness or non-psychotic bipolar disorder who had been admitted to hospital at least once within the previous two years. INTERVENTION: Joint crisis plan formulated by the patient, care coordinator, psychiatrist, and project worker containing contact information, details of illnesses, treatments, relapse indicators, and advance statements of preferences for care for future relapses. Control group was standardised service information. MAIN OUTCOME MEASURES: Admission to hospital; service use over 15 months. RESULTS: Use of a joint crisis plan was associated with less service use and lower costs on average than in the standardised service information group, but differences were not significant. Total costs during follow-up were 7264 pounds sterling (10,616 euros, 13,560 dollars) for each participant with a joint crisis plan and 8359 pounds sterling (12,217 euros, 15,609 dollars) for each participant with standardised service information (mean difference 1095 pounds sterling; 95% confidence interval -2814 to 5004). Cost effectiveness acceptability curves, used to explore uncertainty in estimates of costs and effects, suggest there is a greater than 78% probability that joint crisis plans are more cost effective than standardised service information in reducing the proportion of patients admitted to hospital. CONCLUSION: Joint crisis plans produced a non-significant decrease in admissions and total costs. Though the cost estimates had wide confidence intervals, the associated uncertainty suggests there is a relatively high probability of the plans being more cost effective than standardised service information for people with psychotic disorders.

Community Mental Health Services↗
PubMed2006

Medication adherence in schizophrenia: exploring patients', carers' and professionals' views.

One of the major clinical problems in the treatment of people with schizophrenia is suboptimal medication adherence. Most research focusing on determinants of nonadherence use quantitative research methods. These studies have some important limitations in exploring the decision-making process of patients concerning medication. In this study we explore factors influencing medication adherence behavior in people with schizophrenia using concept mapping. Concept mapping is a structured qualitative method and was performed in 4 European countries. Participants were 27 patients with schizophrenia, 29 carers, and 28 professionals of patients with schizophrenia. Five clinically relevant themes were identified that affect adherence: medication efficacy, external factors (such as patient support and therapeutic alliance), insight, side effects, and attitudes toward medication. Importance ratings of these factors differed significantly between professionals and carers and patients. Professionals, carers, and patients do not have a shared understanding of which factors are important in patients' medication adherence behavior. Adherence may be positively influenced if professionals focus on the positive aspects of medication, on enhancing insight, and on fostering a positive therapeutic relationship with patients and carers.

Adult↗
PubMed2006

Ethnic differences in mental health service use among patients with psychotic disorders.

BACKGROUND: There are concerns that ethnic minority patients are over-represented in inpatient mental health settings, but under-utilise community services. This study aims to compare the use of community mental health services between African-Caribbean and White patients with psychosis, before and after the introduction of new community services, and to investigate their impact on inpatient treatment. METHODS: The sample was drawn from epidemiologically representative patients with psychotic disorders living in two catchment areas in South London, one of which was developing intensive community treatments. Service utilisation was measured at baseline and at 2-year follow-up using the Client Service Receipt Interview (CSRI). The mean number of contacts with specific services was compared between the two groups over time. RESULTS: A total of 92 White and 48 African-Caribbean patients were compared. The latter were more likely to be younger (P = 0.004), have shorter illness duration (P < 0.001), and had more detentions under the Mental Health Act (P = 0.003). No significant differences were seen in use of community services over time. However, intensive treatment led to a significant reduction in hospital days for African Caribbean patients compared to White patients in the intensive sector and all patients in the standard sector. CONCLUSIONS: Intensive community treatments reduced inpatient days in African Caribbean patients. Further effort is needed to improve the cultural sensitivity of community mental health services.

Adult↗
PubMed2006

Pre-morbid IQ and response to routine outcome assessment.

BACKGROUND: Routine use of standardized outcome measures within adult mental health services is compulsory in many countries, but not common in clinical practice. As well as political and professional factors, one reason may be that there is little empirical evidence of benefit for patients. It is therefore important to identify predictors of response. Pre-morbid intellectual functioning has predicted response to other interventions. This paper tests the hypothesis that pre-morbid IQ impacts on the effectiveness of routine assessment and feedback of outcome measures. METHOD: The Feedback of Outcomes to Users and Staff (FOCUS) single-blind randomized controlled trial (RCT) investigated routine completion and feedback of outcome measures for 160 (101 intervention, 59 control) adult mental health service patients in Croydon, South London (International Standard RCT Number 16971059). RESULTS: Patients in the top quarter (pre-morbid IQ>110) differentially improved in patient-rated unmet need (adjusted difference 3.4, 95% CI 0.8 to 5.9, p=0.012) and in the top half (pre-morbid IQ>99) in quality of life (adjusted difference -0.6, 95% CI -1.1 to -0.1, p=0.02). The top quarter result remained when controlling for the influence of baseline (p=0.004) and baseline plus follow-up variables (p=0.047). CONCLUSIONS: Feedback of routine outcome measures may improve outcome for patients with higher pre-morbid IQ. There is a need to understand more how routine outcome information is used by staff and patients to inform care. If the goal of routine use of outcome measures is to benefit patients directly, then targeted policies are required.

Adolescent↗
PubMed2006

Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors.

BACKGROUND: There are few mental health data for Somali people. This is due to the absence of culturally validated appropriate assessment instruments and methodological challenges. We aimed to develop a culturally appropriate instrument, and address the methodological challenges and assess some risk factors for mental disorder among Somalis in London. METHODS: Following a comprehensive process of cultural adaptation of the MINI Neuropsychiatric Interview, we assessed ICD-10 mental disorders among 143 Somalis recruited from GP registers and community sites. Associations with demographic and economic characteristics, sampling venues, cultural and migration related risk factors are reported. RESULTS: A higher risk of mental disorders was found among Somalis who used Khat (OR = 10.5, 1.1-98.3) claimed asylum at entry to the UK (OR = 12.8, 2-81.4) and recruits from primary care rather than from community sites (OR = 5.9, 1.4-25.8). A lower risk of mental disorders was found amongst Somalis in employment (OR = 0.03, 0.01-0.61), and those receiving education in the UK and in Somalia (OR = 0.13, 0.02-0.92). Over a third of subjects had any mental disorder (36.4%, 28.4-44.4), mainly common mental disorders (CMD) (33.8%, 26-41.5) and post-traumatic stress disorder (PTSD) (14%, 8.8-20.8). CMD were found among 80% of those with PTSD. CONCLUSION: Public health interventions for Somalis should focus on CMD as well as PTSD, khat use and mental health screening for suicide risk and mental disorders on arrival.

Adolescent↗
PubMed2006

Seven criteria for improving effectiveness trials in psychiatry.

BACKGROUND: There are no published criteria for improving the quality of effectiveness of randomized controlled trials (RCTs) in psychiatry. METHOD: The authors review and systematize the relevant literature on effectiveness trials, with particular reference to psychiatry. RESULTS: In planning effectiveness RCTs in psychiatry, seven sets of issues need to be carefully considered: (i) study question (i.e. is the study question expressed in an answerable way?); (ii) reference population (i.e. what is the reference group or subgroup to which the trial results should be generalized?); (iii) patient sample (i.e. how far does the sample reflect the target population?); (iv) study settings (i.e. how representative are the study settings of routine clinical sites?); (v) study interventions (i.e. is the study intervention manualized, acceptable to patients and suitable for widespread use?); (vi) control condition (i.e. are the key characteristics of the control condition well described, and do they vary within and between sites?); and (vii) bias (e.g. attrition, blinding, concealment, consent and contamination). CONCLUSIONS: More effectiveness trials are needed which have sufficient statistical power to provide precise answers to assist clinicians in making treatment decisions. The development of effectiveness trials in psychiatry, both for studies of individual treatments and for service evaluations, may be enhanced by carefully considering and justifying decisions in relation to each of the seven key headings proposed here.

Bias↗
PubMed2006

Persistence with polypharmacy and excessive dosing in patients with schizophrenia treated in four European countries.

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.

Adolescent↗
PubMed2006

The development of a Local Index of Need (LIN) and its use to explain variations in social services expenditure on mental health care in England.

Wide variations in deprivation exist across England and it is likely that these variations translate into differences in the need for mental health care. Social Services Departments in England account for a substantial proportion of mental health expenditure. It is important that the distribution of expenditure reflects mental health needs. This paper's aims are to (1) describe the development of a new indicator of mental health needs, (2) use the index to explain variations in social services expenditure on mental health, and (3) compare the index with other established measures of need. A principal components analysis of sociodemographic variables considered to be indicators of need was used to produce four distinct factors for 148 Local Authority areas in England. A weighted sum of these factors was used to produce a single index. (Weights were the proportion of variance explained by each factor.) The index was used in a regression model to explain variations in spending on mental health care and was compared with (1) a model containing the four individual factors, (2) the current method of allocating resources, (3) the index used to allocate resources to primary care trusts, (4) the Mental Illness Needs Index (MINI), (5) four indices of deprivation produced by the Office of the Deputy Prime Minister, and (6) the average of the above four indices. The new index could explain 54% of variation, compared with 56% using the current method. The four-factor model could explain 66%, whilst the other models could explain between 37% and 20%. This new index has the advantage that it is not based on previous levels of utilisation or expenditure and yet still explains a comparable amount of variation as the current method. However, a disaggregated model containing individual factors may be preferable.

Adolescent↗
PubMed2006

Patient preference randomised controlled trials in mental health research.

The relationship between psychiatric patients'preferences for different treatments and the outcome of interventions is unclear, as the few relevant trials have tended to be underpowered. Strong patient preferences result in patients refusing to enter a trial. This leads to bias and limits generalisability, and the patient preference randomised controlled trial (RCT) design has been proposed as an alternative. Limitations and advantages of patient preference RCTs are discussed.

Humans↗
PubMed2006

Ethnic differences among patients in high-security psychiatric hospitals in England.

BACKGROUND: Black (Black Caribbean and Black African) patients are over-represented in admissions to general adult and medium-security psychiatric services in England. AIMS: To describe the sociodemographic, clinical and offence characteristics of patients in high-security psychiatric hospitals (HSPHs) in England, and to compare admission rates and unmet needs by ethnic group. METHOD: A total of 1255 in-patients were interviewed, and their legal status, socio-demographic characteristics and individual treatment needs were assessed. RESULTS: Black patients in HSPHs are over-represented by 8.2 times (range 3.2-24.4,95% CI 7.1-9.3), are more often male (P=0.037), and are more often diagnosed with a mental illness and less often diagnosed with a personality disorder or learning disability (P<0.001) than White patients. Unmet needs were significantly less common among White than among Black patients (mean values of 2.22 v. 2.62, difference=0.40,95% CI 0.06-0.73). CONCLUSIONS: Compared with the proportion of Black patients in the general population in their region of origin, a much higher proportion of Black patients were admitted to HSPHs, and fewer of their needs were met.

Adult↗
PubMed2006

Use of standardised outcome measures in adult mental health services: randomised controlled trial.

BACKGROUND: Routine use of standardised outcome measures is not universal. AIMS: To evaluate the effectiveness of standardised outcome assessment. METHOD: A randomised controlled trial, involving 160 representative adult mental health patients and paired staff (ISRCTN16971059). The intervention group (n=101) (a) completed monthly postal questionnaires assessing needs, quality of life, mental health problem severity and therapeutic alliance, and (b) received 3-monthly feedback. The control group (n=59) received treatment as usual. RESULTS: The intervention did not improve primary outcomes of patient-rated unmet need and of quality of life. Other subjective secondary outcome measures were also not improved. The intervention reduced psychiatric inpatient days (3.5 v.16.4 mean days, bootstrapped 95% CI1.6-25.7), and hence service use costs were 2586 UK pounds (95% CI 102-5391) less for intervention-group patients. Net benefit analysis indicated that the intervention was cost-effective. CONCLUSIONS: Routine use of outcome measures as implemented in this study did not improve subjective outcomes, but was associated with reduced psychiatric inpatient admissions.

Adult↗
PubMed2006

Adherence therapy for people with schizophrenia. European multicentre randomised controlled trial.

BACKGROUND: There is equivocal evidence of the effectiveness of adherence therapy in improving treatment adherence and clinical outcomes for people with schizophrenia. AIMS: To evaluate the effectiveness of adherence therapy in improving quality of life for people with schizophrenia. METHOD: A 52-week, single-blind, multicentre randomised controlled trial of the effectiveness of adherence therapy. Participants were individually randomised to receive eight sessions of adherence therapy or health education. Assessments were undertaken at baseline and at 52-week follow-up. RESULTS: Adherence therapy was no more effective than health education in improving quality of life. CONCLUSIONS: This effectiveness trial provides evidence for the lack of effect of adherence therapy in people with schizophrenia with recent clinical instability, treated in ordinary clinical settings.

Adult↗
PubMed2005

Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: a qualitative study.

Migration is known to be associated with poor health outcomes for certain marginalised and socially disadvantaged populations. This paper reviews a number of reasons why residential mobility in the 'host' country may be associated with poor mental health for refugee populations and reports on a qualitative study of Somalis living in London, UK, and their beliefs about the relationship between residential mobility, poor health and health service use. Two discussion groups were undertaken with 13 Somali professionals and four groups with 21 lay Somalis in East and South London, UK. Lay Somalis did not wish to move accommodation but felt they were forced to move. Some Somali professionals believed that the nomadic history of Somalis made them more likely to elect to move in order to escape problems of living, but this was not supported by the lay group. Frequent geographical movements were seen as stressful and undesirable, disrupted family life and child development and were detrimental to well being. Residential mobility was also perceived to interfere with health care receipt and therefore should be more comprehensively assessed in larger quantitative studies.

Adult↗
PubMed2005

Factor solution of the BPRS-expanded version in schizophrenic outpatients living in five European countries.

RATIONALE: The expanded version of the Brief Psychiatric Rating Scale (BPRS-E) has improved the instrument's coverage and interrater reliability, but there is little knowledge on its subsyndromes. OBJECTIVES: To assess: (1) whether there are common underlying BPRS-E subscales in patients living in different countries and (2) if this is the case, whether these subscales behave the same in all populations and, if not, what are the differences over these populations. METHODS: Data are part of the EPSILON study, a collaborative project carried out in Denmark, England, Holland, Italy and Spain. A random representative sample of 404 adult patients with a ICD-10 diagnosis of schizophrenia who have been in contact with mental health services of a defined catchment area in each site were assessed. Simultaneous component analysis (SCA) was used to find component weights that optimally explain the variance of the variables in different populations simultaneously. RESULTS: Symptom severity differed significantly among the five EPSILON sites in 12 out of 24 BPRS-E items, but a common component solution could be found. It explained 48.8% of the variance and gave four well-interpretable components: manic excitement/disorganization, depression/anxiety, negative and positive symptoms. Each component's internal consistency and intercomponent correlation matrix differed significantly among sites. The four components mean score differed significantly among sites for negative symptoms and depression/anxiety. CONCLUSIONS: In spite of the heterogeneity of symptom's severity in the various countries, the way symptoms cluster in schizophrenia is rather stable cross-culturally. Data demonstrate that to explore schizophrenia a third component, including mania/disorganization items, is necessary beside the positive-negative symptom dimensions. The subscales derived from these analyses can be readily used in clinical trials and epidemiological studies.

Adult↗
PubMed2005

Perceived coercion at admission to psychiatric hospital and engagement with follow-up--a cohort study.

BACKGROUND: Measures of perceived coercion at psychiatric hospital admission have been developed. We aimed to investigate predictors of perceived coercion in subjects admitted to psychiatric hospital in the UK, and to test the hypothesis that high perceived coercion at admission predicts poor engagement with community follow-up. METHOD: A cohort of consecutively admitted subjects were interviewed at admission and before discharge, and were followed prospectively for 10 months. Service use and compliance with care were rated from case notes and by clinicians. RESULTS: One hundred interviews were obtained from 118 consecutive admissions (85%). Compulsory admission was strongly associated with perceived coercion, but one-third of voluntary patients felt highly coerced, and two-thirds were not certain they were free to leave hospital. Greater age, less insight, and non-white ethnicity were associated with high perceived coercion. Perceived coercion did not predict engagement with follow-up. CONCLUSIONS: Services recognise provision of care in the least restrictive setting as a key objective. Perceived coercion should be regarded as an important outcome measure in service evaluation.

Adult↗
PubMed2005

Active ingredients in anti-stigma programmes in mental health.

This paper draws upon a review of the relevant literature and the results of the recent Mental Health Awareness in Action (MHAA) programme in England to discuss the current evidence base on the active ingredients in effective anti-stigma interventions in mental health. The MHAA Programme delivered educational interventions to 109 police officers, 78 adults from different community groups whose working lives involved supporting people with mental health problems but who had received no mental health training and 472 schools students aged 14-15. Each adult target group received two intervention sessions lasting two hours. The two school lessons were 50 minutes each. Knowledge, attitudes and behavioural intent were assessed at baseline and follow-up. In addition focus groups were held with mental health service users to explore the impact of stigma on their lives and facilitators of educational workshops were interviewed to provide expert opinion on 'what works' to reduce psychiatric stigma. Personal contact was predictive of positive changes in knowledge and attitudes for the school students but not the police officers or community adult group. The key active ingredient identified by all intervention groups and workshop facilitators were the testimonies of service users. The statements of service users (consumers) about their experience of mental health problems and of their contact with a range of services had the greatest and most lasting impact on the target audiences in terms of reducing mental health stigma.

Adolescent↗