Catherine Manley

Systematic review of involving patients in the planning and development of health care

Abstract Objective: To examine the effects of involving patients in the planning and development of health care. Data sources:Published and grey literature. Study selection: Systematic search for worldwide reports written in English between January 1966 and October 2000. Data extraction: Qualitative review of papers describing the effects of involving patients in the planning and development of health care. Results: Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported. Conclusions: Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.

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.

Patients or partners? Case studies of user involvement in the planning and delivery of adult mental health services in London

User or patient involvement (UI) in the planning and delivery of health services is an aspiration of many industrialized economies, and has been promoted by United Kingdom (UK) governments for over two decades. This paper reports the findings of qualitative case studies of UI in two mental health provider Trusts in London. Semi-structured interviews were conducted with a variety of stakeholders, including Trust staff at all levels and user group members, to compare the expectations of diverse stakeholders and the extent to which these were achieved. We found that UI remained in the gift of provider managers: providers retained control over decision making, and expected users to address Trust agendas and conform to Trust management practices. Users wanted to achieve concrete changes to policies and services, but had broader aspirations to improve the status and condition of people with mental health problems. Suggestions are made about the direction of future strategies to improve UI.

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.

Predicting violence in schizophrenia: a prospective study

BACKGROUND People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice. AIMS To estimate the risk factors for assault in patients with schizophrenia. METHODS Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up. RESULTS Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17-4.61), a previous violent conviction (OR 2.02, 95% CI 1.04-3.87), having received special education (OR 2.76, 95% CI 1.22-6.26) and alcohol abuse (OR 3.55, 95% CI 1.24-10.2). CONCLUSIONS Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

Abstract Objectives: To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management. Design: Randomised controlled trial with two year follow up. Setting: Four inner city community mental health services. Participants: 708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group. Intervention: Intensive case management (caseload 10–15 per case manager) for two years compared with standard case management (30-35 per case manager). Main outcome measure: Physical assault over two years measured by interviews with patients and case managers and examination of case notes. Results: No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86). Conclusions: Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care. What is already known on this topic Psychosis and violence are known to be associated Community psychiatric interventions aimed at reducing the risk of violence have not been evaluated What this study adds Increasing the intensity of contact between patients and case managers does not reduce the prevalence of violent behaviour in patients with psychosis Younger age, learning difficulties, and a history of violence, drug misuse, and victimisation predict violent behaviour in psychotic patients

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.

Does socioeconomic status predict course and outcome in patients with psychosis

Background We examined the relationship between socioeconomic status (SES) and course and outcome of patients with psychosis. Two hypotheses were examined: a) patients with higher best-ever SES will have better course and outcome than those with lower best-ever SES, and b) patients with greater downward drift in SES will have poorer course and outcome than those with less downward drift. Method Data were drawn from the baseline and 2-year follow-up assessments of the UK700 Case Management Trial of 708 patients with severe psychosis. The indicators of SES used were occupational status and educational achievement. Drift in SES was defined as change from best-ever occupation to occupation at baseline. Results For the baseline data highly significant differences were found between best-ever groups and negative symptoms (non-manual vs. unemployed – coef −10.5, p=0.000, 95 % CIs 5.1–15.8), functioning (non-manual vs. unemployed – coef −0.6, p=0.000, 95 % CIs 0.3 to −0.8) and unmet needs (manual vs. unemployed – coef 0.5, p=0.004, 95 % CIs 0.2–0.9). No significant differences between best-ever groups were found for days in hospital, symptoms, perceived quality of life and dissatisfaction with services. Significant differences for clinical and social variables were found between drift and non-drift SES groups. There were no significant findings between educational groups and clinical and social variables. Conclusions Best-ever occupation, but not educational qualifications, appeared to predict prognosis in patients with severe psychosis. Downward drift in occupational status did not result in poorer illness course and outcome.

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.

Prevalence and predictors of parasuicide in chronic psychosis

This study estimates the prevalence of and risk factors for parasuicide in a large community‐based sample of patients with chronic psychosis.