Tim Millar

Improving the psychiatric skills of established general practitioners: evaluation of group teaching

Summary. Ten established general practitioners, eight of whom were also trainers, took part in a course designed to improve their psychiatric interviewing skills. Participants were instructed in the problem‐based model with audiotape and videotape feedback of real consultations in a group setting. Although those attending were experienced practitioners with a particular interest in the management of psychological problems, evaluation demonstrated a significant improvement in their skills after training. It is suggested that trainers could be trained to provide a similar teaching experience for their own trainees.

Improving the skills of established general practitioners: the long-term benefits of group teaching.

Summary. This study set out to determine the long‐term benefits of teaching psychiatric interview skills. Nine established general practitioners, eight of whom were also trainers, took part some 18 months after attending a problem‐based interviewing course. Interview skills were assessed by rating behaviour during 10‐minute videorecorded simulated consultations with role‐players, recorded before and after training and at follow‐up. The finding of an earlier study that, in terms of the course model, training successfully modified the doctors behaviour, was largely replicated. In addition, not only were acquired skills maintained but further change took place during the follow‐up period, change that can be seen as improvement in terms of the course model.

Training general practitioners to teach psychiatric interviewing skills: an evaluation of group training.

Summary. Group teaching in problem‐based interviewing based on video and audiotape feedback of the doctors own consultations significantly improved the ability of experienced general practitioners to teach psychiatric skills to their trainees. When the GPs were randomly allocated to one of three further training experiences — video feedback of their tutorial sessions, discussion about how to teach and no further teaching, there were very few differences between the groups. The greatest impact on improving teaching skills was brought about by watching their own consultations in a group feedback setting.

Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England

Abstract Aims To compare the change in illicit opioid users’ risk of fatal drug‐related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion. Design National data linkage cohort study of the English National Drug Treatment Monitoring System and the Office for National Statistics national mortality database. Data were analysed using survival methods. Setting All services in England that provide publicly funded, structured treatment for illicit opioid users. Participants Adults treated for opioid dependence during April 2005 to March 2009: 151 983 individuals; 69% male; median age 32.6 with 442 950 person‐years of observation. Measurements The outcome was fatal DRP occurring during periods in or out of treatment, with adjustment for age, gender, substances used, injecting status and CJS referral. Findings There were 1499 DRP deaths [3.4 per 1000 person‐years, 95% confidence interval (CI) = 3.2–3.6]. DRP risk increased while patients were not enrolled in any treatment [adjusted hazard ratio (aHR) = 1.73, 95% CI = 1.55–1.92]. Risk when enrolled only in a psychological intervention was double that during OAP (aHR = 2.07, 95% CI = 1.75–2.46). The increased risk when out of treatment was greater for men (aHR = 1.88, 95% CI = 1.67–2.12), illicit drug injectors (aHR = 2.27, 95% CI = 1.97–2.62) and those reporting problematic alcohol use (aHR = 2.37, 95% CI = 1.90–2.98). Conclusions Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.

National record linkage study of mortality for a large cohort of opioid users ascertained by drug treatment or criminal justice sources in England, 2005–2009

Highlights • Opioid user mortality is almost 6 times higher than in the general population.• Mortality is elevated for a range of diseases and for homicide and suicide.• Excess mortality persists into old age and for some causes is exacerbated.• Drug-related poisoning (DRP) accounts for just under a half of opioid user deaths.• Young female DRP mortality is lower than male but the difference narrows with age.

Capture-recapture estimates of problem drug use and the use of simulation based confidence intervals in a stratified analysis.

STUDY OBJECTIVE To establish the prevalence of problem drug use in the 10 local authorities within the Metropolitan County of Greater Manchester between April 2000 and March 2001. SETTING AND PARTICIPANTS Problem drug users aged 16-54 resident within Greater Manchester who attended community based statutory drug treatment agencies, were in contact with general practitioners, were assessed by arrest referral workers, were in contact with the probation service, or arrested under the Misuse of Drugs Act for offences involving possession of opioids, cocaine, or benzodiazepines. DESIGN Multi-sample stratified capture-recapture analysis. Patterns of overlaps between data sources were modelled in a log-linear regression to estimate the hidden number of drug users within each of 60 area, age group, and gender strata. Simulation methods were used to generate 95% confidence intervals for the sums of the stratified estimates. MAIN RESULTS The total number of problem drug users in Greater Manchester was estimated to be 19 255 giving a prevalence of problem drug use of 13.7 (95% CI 13.4 to 15.7) per 1000 population aged 16-54. The ratio of men to women was 3.5:1. The distribution of problem drug users varied across three age groups (16-24, 25-34, and 35-54) and varied between the 10 areas. CONCLUSIONS Areas in close geographical proximity display different patterns of drug use in terms of prevalence rates and age and gender patterns. This has important implications, both for future planning of service provision and for the way in which the impact of drug misuse interventions are evaluated.

Capture—recapture and anchored prevalence estimation of injecting drug users in England: national and regional estimates

Capture—recapture (C—RC) using four data sources, one of which accounted for 81% of captured injectors, and multiple indicator methods (MIM) were used to obtain national, regional and local estimates of the prevalence of injecting drug use among opiate and/or crack cocaine users in England. Persons aged 15 to 64 years, in contact with health and/or criminal justice services during 2005/2006, and known to be using opiates and/or crack cocaine and injecting drugs were included in the C—RC analysis. The MIM analysis included indicators relating to drug treatment, drug-related deaths, population density and drug offences. There were an estimated 130,000 opiate and/or crack cocaine users who injected drugs in 2005/06 (95% confidence interval 125,800 to 137,000), corresponding to 3.9 per thousand of the population aged 15 to 64 years (95% confidence interval 3.8—4.1). Regional variation in the prevalence of injecting was evident, ranging from 6.1 per thousand of the population aged 15 to 64 years in Yorkshire and the Humber (95% confidence interval 5.6 to 6.6) to 2.3 per thousand in the East of England (95% confidence interval 1.8 to 2.9). Application of gender and age-group distributions for treated injecting drug users (IDUs) to the prevalence estimates suggested that there were 97,200 male injectors (95% confidence interval 94,000 to 102,500) and 63,600 female injectors aged 25 to 34 years (95% confidence interval 61,500 to 67,000). The prevalence estimates provide a basis from which numbers of current IDUs infected with hepatitis C virus (HCV) can be approximated.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation

BACKGROUND The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.

Validation of the University of Manchester Drug Misuse Database.

OBJECTIVE: The study was conducted to assess the validity and quality of data held by one of the UK regional drug misuse databases (DMD). DESIGN: The research was multi-centred and used retrospective analysis to assess the validity of data held on the database. SETTING: The Regional Database is managed at the University of Manchester Drug Misuse Research Unit and uses data returned by medical and non-medical services within the UKs former North Western Regional Health Authority. MATERIAL: The research was largely based on analysis of the reporting or non-reporting to DMD of 1526 presentations by drug users to four community drug teams (CDTs) during the course of 1993. Two datasets were used: the DMD dataset, based on returns to the regional database from the agencies in question; and agency client records. Additionally the data included on a random sample of 300 database forms returned by these CDTs were compared with information contained in client records. MAIN OUTCOME MEASURES: The study reports on how well DMD is functioning in relation to the correct reporting of episodes of problem drug use and the quality of data held. RESULTS: A very high level of agreement (0.875 +/- 0.017, 95% CI, kappa coefficient 0.728) was established between reports sent in to the database and those expected by examination of agency records. The database figures underestimated the total number of episodes that should have been reported by a factor of 0.008. It was also established that 0.906 (+/- 0.018, 95% CI) of the reports made to the database were made correctly, that 0.178 (+/- 0.030, 95% CI) of eligible presentations were not reported, and that 0.166 (+/- 0.030, 95% CI) of ineligible presentations were mistakenly reported. Lastly, it was established that data were unnecessarily missing or inaccurately recorded in 0.027 of cases and that data entry errors occurred in 0.015 of cases. CONCLUSIONS: The validation project showed that the DMD system is very reliable, providing accurate measures of the extent and nature of presenting problem drug use in the region under study.

Glossary of terms relating to capture-recapture methods

This glossary provides basic definitions for terms that have a specific meaning in the application of the capture–recapture methodology, particularly with respect to standard techniques for the application of log linear models to multiple lists. In epidemiology, capture–recapture is used for prevalence estimation. It is intended that, as well as being a central point of reference for terms used in the capture–recapture methodology, this glossary should provide a resource for those new to this methodology. It aims to provide a simple introduction using terms that should be understood by an uninitiated audience.