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Biomedical subjects

P Tyrer

Publications and source records attributed to P Tyrer.

At least 55 records · Page 3Linked to original sources
PubMed2000

Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial.

One hundred fifty-five (77%) of 201 participants recruited in a trial of intensive vs standard case management of patients with recurrent psychotic illness had their personality status measured before treatment and were followed up for two years. The primary outcome was the total number of days spent in psychiatric hospitalisation in the two years following randomisation. Thirty-three (21%) of the patients had a personality disorder and their duration of hospital stay (105 days) was greater than in those without personality disorder (56 days). There was weak evidence that intensive case management more effective in reducing the duration of care in those with personality disorder than in those without personality disorder.

Adult↗
PubMed2000

Problems in developing an instrument for the rapid assessment of personality status.

PURPOSE: To assess the validity of a quick assessment instrument (10 minutes) for assessing personality status, the Rapid Personality Assessment Schedule (PAS-R). SUBJECTS AND METHODS: The PAS-R was evaluated in psychotic patients recruited in one of the centres involved in a multicentre randomised controlled trial of intensive vs standard case management (the UK700 case management trial). Patients were assessed using both a full version of the PAS (PAS-I - ICD version) and the PAS-R. The weighted kappa statistic was used to gauge the (criterion-related) validity of the PAS-R using the PAS-I as the gold standard. Both measure code personality status using a four-point rating of severity in addition to recording individual categories of personality disorder. RESULTS: One hundred fifty-five (77%) of 201 patients recruited were assessed with both instruments. The weighted kappa statistic was 0.31, suggesting only moderate agreement between the PAS-I and PAS-R instruments under the four-point rating format, and 0.39 for the dichotomous personality disorder/no disorder separation. The sensitivity (64%) and specificity (82%) of the PAS-R in predicting PAS-I personality disorder were as satisfactory as for other screening instruments but still somewhat disappointing, and the PAS-R had an overall diagnostic accuracy of 78%. CONCLUSION: The PAS-R is a quick and rough method of detecting personality abnormality but is not a substitute for a fuller assessment.

Adult↗
PubMed2000

Patient satisfaction: a valid index of quality of care in a psychiatric service.

OBJECTIVE: To assess patients', clinicians' and referrers' satisfaction with care in newly referred psychiatric patients and to compare these with standard quality indicators such as waiting times used by the service. METHOD: A random sample of all new adult psychiatric patients presenting over a 4-month period in 2 successive years to an inner-city psychiatric service was assessed. RESULTS: One hundred and thirteen (68%) of 167 randomly selected patients were seen. Independent evidence of service performance showed that patient satisfaction, but not clinician or referrer satisfaction, was a more accurate indicator of quality of care than standard indicators. CONCLUSION: Simple ratings of patient satisfaction alone may be useful indicators of quality of psychiatric care.

Adolescent↗
PubMed2000

Longitudinal study of the influence of life events and personality status on diagnostic change in three neurotic disorders.

It has been known for many years that diagnosis within the neurotic spectrum of disorders is temporally unstable and also that life events can be major precipitants of change in symptoms. Reasons for this instability could include inherent inadequacy of current diagnostic practice, the influence of life events as an agent of diagnostic shift, and an innate course of disorder with features dependent on the stage at which disorder presents (e.g., development of panic to agoraphobia). These possibilities were examined in a prospective study that was initially a randomised controlled trial. Two hundred ten patients recruited from primary care psychiatric clinics with DSM-III diagnosed dysthymic, generalised anxiety, and panic disorders were randomly allocated to either drug treatment (mainly antidepressants), cognitive-behaviour therapy, or self-help therapy over a 2 year period, irrespective of original diagnosis. Life events were recorded by using a standard procedure over the period 6 months before starting treatment and at five occasions over 2 years; 181 (86%) of the patients had follow-up data and 76% maintained compliance with the original treatment allocated over the 2 years; and 155 of the 181 patients (86%) had at least one diagnostic change in this period. There was no difference in the number of diagnostic changes between the three original diagnostic groups, but dysthymic disorder changed more frequently to major depressive episode than did GAD or panic disorder (20; 11; 12) (%) and panic disorder changed more frequently to agoraphobia (with or without panic) than did dysthymia or GAD (18; 8; 6) (%). There was no relationship between loss events and depressive diagnoses or between addition events and anxiety diagnoses, but greater numbers of conflict events were associated with diagnostic change. More life events were associated with the flamboyant and dependent personality disorders, reinforcing other evidence that many life events are internally generated by personality characteristics and cannot be regarded as truly independent.

Cognitive Behavioral Therapy↗
PubMed1999

Intensive versus standard case management for severe psychotic illness: a randomised trial. UK 700 Group.

BACKGROUND: Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased. Despite equivocal results, in the UK and Europe, this approach is becoming accepted policy. We assessed the effect of smaller case loads. METHODS: We randomly assigned 708 psychotic patients in four centres standard case management (355 patients, case load 30-35 per case manager) or intensive case management (353 patients, case load 10-15 per case manager). We measured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients. Analysis was by intention to treat. FINDINGS: There was no significant decline in overall hospital use among intensive-case-management patients (mean 73.5 vs 73.1 days in those who received standard care [SD 0.4, 95% CI -17.4 to 18.1]), nor were there any significant gains in clinical or social functioning. There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients. INTERPRETATION: In well-coordinated mental-health services, a decline in case load alone does not improve outcome for these patients. Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation.

Adolescent↗
PubMed1999

Long-term outcome of hypochondriacal personality disorder.

Hypochondriacal personality disorder diagnosed according to the Personality Assessment Schedule, a structured clinical interview, was related to outcome after 2 years and 5 years in a randomized, controlled trial of treatment of generalized anxiety, panic, and dysthymic disorders. Seventeen individuals (9%) from a population of 181 patients had hypochondriacal personality disorder and they experienced a significantly worse outcome than other patients, including those with other personality disorders, in terms of symptomatic change and health service utilization. This lack of improvement was associated with persistent somatization in hypochondriacal personality disorder. The results give further support to the belief that hypochondriacal personality disorder is a valid clinical diagnosis that has important clinical correlates, but further work is needed to establish the extent of its overlap with hypochondriasis as a mental state disorder.

Cognitive Behavioral Therapy↗
PubMed1999

Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm.

BACKGROUND: The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy. METHODS: Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N = 18) or treatment as usual (TAU N = 16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined. RESULTS: Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/month MACT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT (P = 0.22). CONCLUSIONS: Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.

Adolescent↗
PubMed1999

Prevalence and characteristics of patients with severe mental illness and borderline intellectual functioning. Report from the UK700 randomised controlled trial of case management.

BACKGROUND: Low cognitive ability and developmental delays have been implicated in the causation of mental illness. AIMS: To examine the prevalence, socio-demographic characteristics, psychopathology and social functioning profiles of people with low intelligence and recurrent psychotic illness. METHOD: A multi-centre randomised controlled trial of case management provided the opportunity to explore associations between mental illness and borderline intellectual functioning (assessed using the National Adult Reading test). RESULTS: Overall prevalence of borderline intelligence was 18%. Significant positive associations were shown with: being Black Caribbean; having a father who worked in a manual occupation; lower educational achievement; having had special education; longer course of illness. Those with borderline intelligence had greater disability and were more likely to suffer extrapyramidal side-effects and show evidence of negative symptoms. Educational achievement, history of special education and social class were the best socio-demographic predictors of intellectual level. CONCLUSIONS: Many patients who attend generic psychiatric services have considerable intellectual deficits. This may lead to difficulties in other domains of adaptive functioning, and merits further investigation as well as clinical vigilance.

Adolescent↗
PubMed1998

Randomised controlled trial of two models of care for discharged psychiatric patients.

OBJECTIVE: To compare the clinical outcome and costs of care of psychiatric patients allocated to community multidisciplinary teams or to hospital based care programmes after discharge from inpatient care. DESIGN: Randomised controlled trial. SETTING: Inner London (Paddington and North Kensington) and outer London (Brent) psychiatric services. SUBJECTS: 155 patients with severe mental illness with a previous admission within the past 2 years. MAIN OUTCOME MEASURES: Ratings of clinical psychopathology, depression, anxiety, and social functioning; comprehensive costs of health care. RESULTS: Clinical outcomes were available for 133 patients and cost data for 144 patients after 1 year. The clinical outcomes of the two models of care were essentially similar, but admission to hospital was more likely in the hospital based care group and the costs of health care were 14% greater per patient than in the community group. This difference, however, was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London. This was explained largely by greater inpatient care for outer London patients (58 median bed days v 18 for inner London patients), more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study. CONCLUSION: Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital. When psychiatric bed requirements are insufficient for a population, however, neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes, with disintegration and discontinuity of psychiatric services leading to escalating costs.

Adolescent↗