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Biomedical subjects

Peter Tyrer

Publications and source records attributed to Peter Tyrer.

At least 19 recordsLinked to original sources

Comparison of alternative methods of collection of service use data for the economic evaluation of health care interventions.

Economic evaluation of health care interventions usually requires the collection of service use data to estimate the total cost of participants in an evaluation. There are a number of methods available to measure the quantity of services used but little is known about the relative accuracy of alternative methods. In a multicentre randomised controlled trial of interventions for the treatment of adults with recurrent episodes of deliberate self-harm (the POPMACT trial), health service data were collected by patient self-report after six and twelve months and also from GP records by independent investigators. Agreement for overall costs was relatively high. However, this hides substantial variation in agreement between the two sources of information for different services. The results suggest that GP records provide more accurate data on the use of general practice-based contacts than patient report, but less reliable information on contacts with other health services. Thus reliance on GP records for data on hospital services and other community health services based outside of general practice surgeries is not recommended. Future research should explore the level of agreement between patient report and other providing sector records, such as hospital records.

Adult↗

Generalised anxiety disorder.

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

Anti-Anxiety Agents↗

Protein-bound 3,4-dihydroxy-phenylanine (DOPA), a redox-active product of protein oxidation, as a trigger for antioxidant defences.

Protein hydroperoxides and protein-bound 3,4-dihydroxy-phenylanine are amongst the major long-lived redox-active products during free radical attack on proteins. Protein-bound 3,4-dihydroxy-phenylanine can redox cycle between catechol and quinone form, and bind transition metals, whereas hydroperoxides are converted to stable hydroxides. The free amino acid 3,4-dihydroxy-phenylanine is a normal metabolite, an oxidation product of tyrosine, involved in pathways of dopamine and melanin production, and we have shown that it may be incorporated into protein-by-protein synthesis. However, physiological levels of protein-bound 3,4-dihydroxy-phenylanine are very low; yet remarkably elevated levels occur in some pathologies. We propose that, unlike free 3,4-dihydroxy-phenylanine, protein-bound 3,4-dihydroxy-phenylanine is a signal for the activation of cellular defences both against the oxidative fluxes during oxidative stress and against the oxidative damage which sometimes ensues. Unlike free 3,4-dihydroxy-phenylanine, the levels of protein-bound 3,4-dihydroxy-phenylanine can change 5-10-fold during oxidative damage in vivo, an appropriate property for a signalling molecule. We suggest mechanisms by which protein-bound 3,4-dihydroxy-phenylanine might trigger oxidative defences, via NF-kappaB and other transcription factors. Little evidence yet bears directly on this, but we discuss some implications of observations on free 3,4-dihydroxy-phenylanine supply to cells in vitro, to Parkinson's patients, and to animal models of the disease. Several of the effects of 3,4-dihydroxy-phenylanine in these situations may be mediated by the production and actions of protein-bound 3,4-dihydroxy-phenylanine. Some experimental tests of the hypothesis are outlined and some possible therapeutic implications.

Animals↗

Rating scales, scales of measurement, issues of reliability: resolving some critical issues for clinicians and researchers.

We focus upon several broad issues that are of concern to clinicians and clinical researchers in the areas of biobehavioral and biomedical research, including, but not limited to, the fields of psychiatry, psychology, neuropsychology, and neurology. These issues are the critical reassessment of S. S. Stevens' quadripartite conceptualization of scales of measurement; the application of criteria to determine the clinical significance of reliability estimates; the detection of subsets of reliable and unreliable raters, when the overall level is of little clinical import; and finally, the application of Kappa statistics when multiple raters evaluate a single case.

Behavioral Research↗

Management of complex and severe personality disorders in community mental health services.

PURPOSE OF REVIEW: To describe the prevalence and specific management of severe and complex personality disorders in community mental health services and similar settings. RECENT FINDINGS: Conflicting reports exist in the literature but the consensus of evidence suggests that more complex personality disorder (more so than simple personality disorder) impairs response to treatment of most psychiatric disorders and complicates their management. Poor adherence to treatment may be one of the mechanisms underlying this. SUMMARY: Increasing evidence now suggests that more complex and severe personality disorders have a negative impact on the outcome of most psychiatric disorders. Some indications, however, are there to show that pharmacological treatments may not handicap the outcome of pharmacological treatment as much as other types of intervention and may be selectively chosen in this group. Severe personality disorder needs to be identified early in community services as by anticipating and adjusting to its effects it is likely to improve treatment plans and prognosis.

Borderline Personality Disorder↗

Microbial pattern recognition receptors mediate M-cell uptake of a gram-negative bacterium.

The receptors involved in the sampling of particulate microbial antigens by the gut are largely unknown. Here we demonstrate for the first time in an in vitro M-cell model and in situ in isolated murine intestinal segments that the receptors TLR-4, PAF-R, and alpha5beta1 integrin are all involved in mediating bacterial uptake associated with transcytosis. The pattern of expression of TLR-4 and alpha5beta1 integrin differed between M cells and enterocytes. There was increased apical expression of TLR-4 in M-cell cultures, and it was present on the apical surface of murine M cells but not enterocytes in situ. In contrast, PAF-R was expressed equally by both cell types in vitro and was abundantly expressed throughout the intestinal epithelium. Inhibition of TLR-4 and PAF-R, but not TLR-2, reduced gram-negative bacterial uptake by both cell types, whereas inhibition of the apically expressed alpha5beta1 integrin significantly reduced the ability of M cells to translocate bacteria. Hence, the involvement of each receptor was dependent not only on differences in the level of receptor expression but the cellular localization. Using bacteria that had mutations that affected the bacterial lipooligosaccharide structure indicated that the oligosaccharide moiety was important in bacterial uptake. Taken together, the data suggest that pathogen-associated molecular pattern interactions with pattern recognition receptors are key factors in M-cell recognition of intestinal antigens for mucosal immune priming.

Animals↗

The bed requirement inventory: a simple measure to estimate the need for a psychiatric bed.

OBJECTIVE: To develop an assessment of bed need that was as little affected by personal bias as possible. METHOD: The Bed Requirement Inventory (BRI) is an eight-point scale designed to identify the appropriate use of an acute psychiatric bed. This is completed by a member of the ward staff, usually a nurse, and takes 5 minutes to fill in. The reliability, validity and feasibility of using the scale in normal practice were tested in a one-year study, and variations in inappropriate bed use described. RESULTS: The inter-rater reliability of the scale was good (intra-class correlation coefficient = 0.63) and a comparison of the need for a psychiatric bed (comparing the BRI score with the judgement of an independent multidisciplinary group of professionals) also showed good agreement (k = 0.69), suggesting reasonable validity (although when the assessment was made by the named nurse agreement was less good). Results from a year-long survey in two West London hospitals showed that 17% of admissions were inappropriate and 32% had delayed discharge, black Caribbean patients had a significantly higher proportion (25%) of inappropriate admission than others (11%) and those referred from housing charities and hostels had a higher proportion (50%) of inappropriate bed use at some time than other groups (33%). CONCLUSIONS: The Bed Requirement Inventory is a quick and reliable method of determining the appropriate use of a psychiatric bed and could be of use in estimating local bed needs. Delayed discharge remains a serious reason for inappropriate bed use in London.

Adult↗

Personality disorder and the outcome of depression: meta-analysis of published studies.

BACKGROUND: There is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. AIMS: Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined. METHOD: Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies. RESULTS: Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small. CONCLUSIONS: Combined depression and personality disorder is associated with a poorer outcome than depression alone.

Antidepressive Agents↗

Prevalence and correlates of personality disorder in Great Britain.

BACKGROUND: Epidemiological data on personality disorders, comorbidity and associated use of services are essential for health service policy. AIMS: To measure the prevalence and correlates of personality disorder in a representative community sample. METHOD: The Structured Clinical Interview for DSM-IVAxis II disorders was used to measure personality disorder in 626 persons aged 16-74 years in households in England, Scotland and Wales, in a two-phase survey. RESULTS: The weighted prevalence of personality disorder was 4.4% (95% CI 2.9-6.7). Rates were highest among men, separated and unemployed participants in urban locations. High use of healthcare services was confounded by comorbid mental disorder and substance misuse. Cluster B disorders were associated with early institutional care and criminality. CONCLUSIONS: Personality disorder is common in the community, especially in urban areas. Services are normally restricted to symptomatic, help-seeking individuals, but a vulnerable group with cluster B disorders can be identified early, are in care during childhood and enter the criminal justice system when young. This suggests the need for preventive interventions at the public mental health level.

Adolescent↗

Violence in women with psychosis in the community: prospective study.

BACKGROUND: Little is known about the determinants of violence in women with psychosis. AIMS: To identify predictors of violence in a community sample of women with chronic psychosis. METHOD: The 2-year prevalence of physical assault was estimated for a sample of 304 women with psychosis. Baseline socio-demographic and clinical factors were used to identify predictors of assault. RESULTS: The 2-year prevalence of assault in the sample was 17%. Assaultive behaviour was associated with previous violence (OR=5.87,95% CI 2.42-14.25), non-violent convictions (OR=2.63,95% CI 1.17-5.93), victimization (OR=2.46, 95% CI1.02-5.93), African-Caribbean ethnicity (OR=2.24,95% CI1.02-4.77), cluster B personality disorder (OR=2.66, 95% CI1.11-6.38) and high levels of unmet need (OR=1.17,95% CI1.01-1.35). An interaction between African-Caribbean ethnicity and cluster B personality disorder was identified in relation to violent outcome. Violent women were found to be more costly to services. CONCLUSIONS: Nearly a fifth of community-dwelling women with chronic psychosis committed assault over a period of 2 years. Six independent risk factors were found to predict violence.

Adult↗

A randomized controlled trial of cognitive behavior therapy for borderline personality disorder: rationale for trial, method, and description of sample.

This paper describes the rationale for a randomized controlled trial, comparing cognitive behavior therapy in addition to treatment as usual with treatment as usual alone, for borderline personality disorder. Previous pioneering randomized controlled trials of psychotherapies have suffered from methodological weaknesses and have not always been reported clearly to allow adequate evaluation of either the individual study or comparisons across studies to be undertaken. We report on the recruitment and randomization, design, and conduct of an ongoing randomized controlled trial of one hundred and six patients with borderline personality disorder. Primary and secondary hypotheses and their planned analyses are stated. The baseline characteristics of 106 patients meeting diagnostic criteria for borderline personality disorder are described.

Adult↗

The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial.

The outcome of a randomized controlled trial of cognitive behavior therapy in addition to treatment as usual (CBT plus TAU) compared with TAU alone (TAU) in one hundred and six participants meeting diagnostic criteria for borderline personality disorder is described. We anticipated that CBT plus TAU would decrease the number of participants with in-patient psychiatric hospitalizations or accident and emergency room contact or suicidal acts over twelve months treatment and twelve months follow-up, compared with TAU. We also anticipated that CBT plus TAU would lead to improvement in a range of secondary outcomes of mental health and social functioning compared to TAU. Of the 106 participants randomized, follow-up data on 102 (96%) was obtained at two years. Those randomized to CBT were offered an average of 27 sessions over 12 months and attended on average 16 (range 0 to 35). We found that the global odds ratio of a participant in the CBT plus TAU group compared with the TAU alone group having any of the outcomes of a suicidal act, in-patient hospitalization, or accident and emergency contact in the 24 months following randomization was 0.86 (95% confidence interval [CI] 0.45 to 1.66, p = 0.66). The corresponding global odds ratio, excluding accident and emergency room contact, was 0.75 (95% CI 0.37 to 1.54, p = 0.44). In terms of the number of suicidal acts, there was a significant reduction over the two years in favor of CBT plus TAU over TAU, with a mean difference of -0.91 (95% CI -1.67 to -0.15, p = 0.020). Across both treatment arms there was gradual and sustained improvement in both primary and secondary outcomes, with evidence of benefit for the addition of CBT on the positive symptom distress index at one year, and on state anxiety, dysfunctional beliefs and the quantity of suicidal acts at two year follow-up. CBT can deliver clinically important changes in relatively few clinical sessions in real clinical settings.

Adult↗

The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial.

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (-689 pounds sterling), although this group also reported a lower quality of life (-0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study.

Adult↗

Service costs for severe personality disorder at a special hospital.

BACKGROUND: Much attention has been given to the reform of services for people with personality disorder in the UK, yet little is known of the cost of existing services, particularly in secure forensic settings. Existing cost estimates almost always rely on aggregate estimates of the cost of care rather than individual-level costing, but the latter is necessary for the economic evaluation of new services. METHOD: This paper uses a new instrument for recording service use in secure forensic settings to report the service use and care package costs of 16 patients being considered for the dangerous and severe personality disorder programme in the Personality Disorder Directorate at Rampton, a high secure hospital in Nottinghamshire, UK. RESULTS: The mean cost over a six-month period was 65,545 UK pounds (approximately 131,000 pounds per annum) but there was considerable variation within this figure, with a range of 59,119 to 82,709 UK pounds. CONCLUSIONS: Aggregate costs for individuals in secure hospital settings hide substantial variation between individuals. This paper demonstrates the feasibility of estimating the cost of individual care packages in a secure forensic setting.

Data Collection↗

Psychotic symptoms in the general population of England--a comparison of ethnic groups (The EMPIRIC study).

BACKGROUND: There is considerable evidence that incidence of schizophrenia and other psychoses varies across ethnic groups in the UK, with particularly high rates for people of African-Caribbean origin. AIMS: The aims of this shady were to estimate in a community-based sample of people from ethnic minorities: 1) the prevalence of psychotic symptoms; and 2) risk factors for reporting psychotic symptoms. METHOD: Face-to-face interviews were carried out with a probabilistic sample of 4281 adults from six ethnic groups living in the UK. Psychotic symptoms were measured using the psychosis screening questionnaire (PSQ). RESULTS: There was a twofold higher rate of reporting psychotic symptoms on the PSQ in Black Caribbean people compared with Whites. Adjustment for demographic factors had little effect on this association. CONCLUSION: Prevalence rates of psychotic symptoms were higher in people from ethnic minorities, but were not consistent with the much higher first contact rates for psychotic disorder reported previously, particularly in Black Caribbeans.

Adolescent↗

Hopelessness and positive and negative future thinking in parasuicide.

OBJECTIVES: Hopelessness about the future is a key element in suicidal behaviour. The aim of the present study was to examine possible components of hopelessness, in particular, to contrast positive and negative future thinking and to examine separately number, expectancy, and value of anticipated positive and negative future experiences. DESIGN: A correlational design. METHOD: Repeat parasuicide patients (N = 441) were administered the Beck Hopelessness Scale, the Hospital Anxiety and Depression Scale and the future thinking task, a measure of future positive and negative thinking that assesses number, perceived likelihood, and perceived value of anticipated future positive and negative events. RESULTS: Consistent with predictions, hopelessness correlated more strongly with lack of positive thoughts about the future than it did with presence of negative thoughts. Both positive and negative future thinking showed a relationship to hopelessness over and above their relationships to depression (positive future thinking) and anxiety (negative future thinking). Number and likelihood of positive events and likelihood and value of negative events showed both simple and partial relationships to hopelessness. Number of negative events related to hopelessness but only after the other future thinking variables had been controlled for and value of positive events no longer related to hopelessness after controlling for the other variables. CONCLUSIONS: Hopelessness about the future in suicidal individuals is a multi-faceted construct but lack of positive future thinking is more important than presence of negative future thinking.

Adolescent↗