Chris Flood

Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial

Abstract Objective To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment. Design Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation. Setting Eight community mental health teams in southern England. Participants 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years. Intervention The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse. Main outcome measures Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up. Results Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, −61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, −18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference −24, −72 to 24, P = 0.39 for those admitted). Conclusions Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services.

Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro-oesophageal reflux disease†

This study examined the short‐term cost‐effectiveness and long‐term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton‐pump inhibitor (PPI) medication for severe gastro‐oesophageal reflux disease (GORD) based on a randomized clinical trial.

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

Abstract 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 (€10 616,

Constraints and blocks to change and improvement on acute psychiatric wards--lessons from the City Nurses project.

13 560) for each participant with a joint crisis plan and £8359 (€12 217,

Infantile gastroenteritis in the community:a cost-of-illness study

15 609) for each participant with standardised service information (mean difference £1095; 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.

Nurse staffing, bed numbers and the cost of acute psychiatric inpatient care in England

Recent years have seen sustained criticism and inspection of acute inpatient psychiatric wards, with the publication of reports and research leading to policy developments and a variety of efforts to improve perceived deficits. The City Nurses project seeks to reduce levels of conflict and containment on acute wards through the placement of expert nurses on wards to assist with the implementation of changes according to a working model of conflict and containment generation, based on previous research. Evaluation has shown significant decreases in aggression, absconding and self-harm by patients. However, in the course of working with the wards, various constraints and blocks to change have been identified and we describe these in detail in this paper. Analysis of the fieldwork diaries of the two City Nurses identified that change was hindered by limited staffing resources, problems with the physical environment and other resources, insufficient beds and the process of bed management, hierarchical ambiguity and multidisciplinary issues, the overdemanding role of the ward manager, and pervasive anxiety about the potential for serious untoward incidents and their implications for staff. We argue that sustained positive change in acute inpatient psychiatry requires these underlying structural issues to be both acknowledged and, if possible, resolved.

Suicidal behavior and psychological distress in university students: a 12-nation study

Rotavirus infections are the main cause of gastroenteritis in infants and children and it is expected that by the age of 5 years, nearly every child will have experienced at least one episode of rotavirus gastroenteritis. While severe cases are hospitalized, milder disease is either treated at home or by the GP, and as such the true prevalence of rotavirus infection in the community, and the burden of disease, is unknown. This paper reports the results of a cost-of-illness study which was conducted alongside a structured community surveillance study. Forty-eight percent of our sample was found to have rotavirus acute gastroenteritis; and the average total cost of a child presenting with rotavirus gastroenteritis ranged between £59 and £143 per episode, depending on the perspective. Given the prevalence and severity of the disease, the estimated burden of rotavirus gastroenteritis to society is £11.5 million per year.

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

The aim of this analysis was to describe the composition, variability and factors associated with nurse staffing costs in acute psychiatric inpatient care. Numbers of acute inpatient beds in England have fallen, creating an occupancy crisis. Numbers of acute inpatient nursing staff are linked to quality of care. Variance in staffing and beds has considerable resource implications, but little is known about how these costs are structured. The sample comprised survey data from 136 wards in 26 NHS Trusts, matched with nationally available data on service levels, population and outcomes. The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found. As investment in acute inpatient care varies widely, we need to know much more about the relationship of inputs to outputs, so that empirically based standard service levels can be defined.

Cross - national comparisons of attitudes towards suicide and suicidal persons in university students from 12 countries

This study investigated the prevalence of suicidal behavior and psychological distress in university students across 12 nations. A total of 5,572 university students from 12 countries were surveyed about suicide ideation, suicide attempts, and psychological distress by means of a self-administered questionnaire. Almost 29% of the samples reported having contemplated suicide and 7% reported attempting suicide. Of the total sample, 51.1% scored above the General Health Questionnaire-12 ≥ 3 cut-off points, 41.6% above the GHQ-12 ≥ 4 cut-off points, and 33.8% scored above the GHQ-12 ≥ 5 cut-off points. While odds of suicide ideation were elevated in Austria and the UK, reduced ORs were detected for China, Italy, Saudi Arabia, Tunisia, and Turkey. Similarly, while odds of suicide attempt were high in Jordan, Palestine, Saudi Arabia, and to some extent in Turkey, reduced ORs were observed for Austria, China, Italy, Japan and the United States. Elevated ORs for psychological distress were seen in Japan, Jordan, Palestine, Saudi Arabia, Tunisia, and Turkey but reduced ORs were noted in Austria, China, Iran, Italy, and the United States. Psychological distress was strongly associated with reports of suicide ideation and attempts. Suicide ideation, suicide attempt, and psychological distress are common in university students but their rates vary depending on the sociocultural context. Due attention should be devoted to the mental health needs of young adults enrolled in higher educational institutions and more cross-cultural research is warranted to better understand the etiology of the observed intersocietal variations in suicidal behavior and psychological distress.

Barriers and enablers of type 2 diabetes self-management in people with severe mental illness

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.