The London Depression Intervention Trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs.

BACKGROUND: Relapse of depression is associated with a criticising attitude of the patient's partner. AIMS: To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner. METHOD: A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner. RESULTS: Drop-outs were 56.8% [corrected] from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments. CONCLUSIONS: For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.

The TAPS project 32: social networks of two group homes ... 5 years on. Team for the Assessment of Psychiatric Services.

Long-stay psychiatric patients discharged to two group homes from Friern Hospital were studied 1 year and 5 years after discharge. A much greater cohesiveness of social relationships was noted in the smaller home at both time points, whereas in the larger home residents had failed to develop friendships and intimacy within their social group. A number of hypotheses were explored to explain this difference. None of the factors investigated provided an explanation, including the mental state of the patients prior to discharge, their problems of social behaviour, the size of the group homes, whether they were staffed or unstaffed, and the patients' age. However, the development of friendships and intimacy over a 5-year period was strongly determined by the quality of the patients' social networks while in hospital. Consequently, when selecting groups of patients to share homes in the community, it is deemed advisable to form groups that fully reflect the range and diversity of their social networks.

Intrusive memories and depression in cancer patients.

Matched samples of depressed and nondepressed cancer patients were interviewed about past life events, particularly experiences of death and illness. They identified and described any spontaneous intrusive visual memories they had experienced in the past week corresponding to these events. About one quarter reported such memories and, as predicted, the majority of intrusive memories concerned illness, injury and death. The mean levels of intrusion and avoidance were equivalent to patients with post-traumatic stress disorder. Consistent with prediction, depressed patients reported significantly more intrusive memories than controls, and described the memories as typically beginning with or being exacerbated by the onset of depression. Greater numbers of intrusive memories were associated with more maladaptive coping, and greater avoidance with deficits in autobiographical memory functioning.

Memory processes and the course of anxiety and depression in cancer patients.

BACKGROUND: Intrusive memories of stressful events, many involving illness and death, are found in a minority of depressed cancer patients, and may predict the course of anxiety and depression. METHOD: Matched samples of mild to moderately depressed and non-depressed cancer patients were followed up after 6 months. Anxiety and depression at follow-up were related to measures of intrusive memories of stressful life events and autobiographical memory functioning that had been assessed at baseline. RESULTS: Levels of anxiety and depression remained fairly constant over time in the two groups, and the depressed group continued to experience high levels of intrusive memories. The presence of intrusive memories at baseline, and the extent to which these memories were consciously avoided, predicted greater anxiety at follow-up, even after controlling for initial severity of physical and psychiatric symptoms. None of the measures of memory functioning predicted levels of depression at follow-up. CONCLUSIONS: Intrusive memories appear to be a marker of more prolonged psychopathology in cancer patients and may respond to direct therapeutic intervention.

Quality of life of long-stay patients discharged from two psychiatric institutions.

OBJECTIVE: The study compared the quality of life of long-stay psychiatric patients after they had been discharged to community residences for one year with that of long-stay patients who remained hospitalized. METHODS: Long-stay patients (that is, those with stays of at least one year) who were discharged from two psychiatric hospitals in London were closely matched with patients likely to stay in the hospital for another year. Baseline (in-hospital) and one-year follow-up assessments were conducted using six instruments to measure factors related to quality of life such as problems in social functioning and size of the social network. RESULTS: A total of 494 discharged patients were compared with 279 patients who remained in the hospital. The death rate did not differ between the two groups. Only six discharged patients became vagrants, and only two were imprisoned, one briefly. Discharged patients were living under much less restrictive conditions, they preferred their life in the community, and the number of their friends increased, as did the number of acquaintances in the community such as neighbors. No adverse effects of discharge on mental state or social behavior were noted. CONCLUSIONS: The results indicate that community care is a beneficial alternative to long-term care in psychiatric hospitals for the majority of patients, provided it is well planned and adequate resources are available.

The TAPS Project. 12: Crime, vagrancy, death and readmission of the long-term mentally ill during their first year of local reprovision.

The extent of crime, vagrancy, death, and readmission in a prospective cohort of long-term mentally ill patients was measured during their first year out of hospital. All 278 long-stay psychiatric patients discharged during the first three years (1985-1988) of the closure of Friern and Claybury Hospitals were included. One patient was imprisoned, one committed suicide, and one became vagrant; five others may also have become vagrant. The mortality rate was similar for the leavers and their matched controls, who remained in hospital. There was one suicide among the matches. Mental deterioration most often caused readmission. On recovery, most patients returned to their community home. Six per cent of the cohort were readmitted and have remained in hospital for a year or more. With careful planning and a financial 'dowry' for each patient, the closure of large mental hospitals does not lead to a marked increase in vagrancy, crime, and mortality for the long-term mentally ill. However, the patients who have yet to leave have more problems of social behaviour and are likely to be more difficult to resettle.

The TAPS Project. 13: Clinical and social outcomes of long-stay psychiatric patients after one year in the community.

The first prospective, controlled study of a large, long-stay, in-patient population as their hospital services were reprovided in the community is reported. Two-hundred-and-seventy-eight patients were matched individually with similar patients who remained in hospital. Clinical and social outcomes over a one-year follow-up are presented for the first three years of the reprovision process. Compared with matches, the leavers at follow-up had more diverse social networks that contained a higher proportion of contacts named as friends. The care facilities in the community allowed more opportunities for patient autonomy than the hospitals across all aspects of the environments measured. At follow-up, more leavers than matches wanted to remain in their current placement, while fewer leavers than matches said there was nothing they liked about their current placement. More leavers than matches found their medication helpful.

Bulimia nervosa: a 5-year follow-up study.

Fifty patients with bulimia nervosa were followed up for a minimum length of 5 years. Standardized interviews, observer-rated instruments and self-rated questionnaires were employed both at entry and at completion of the follow-up period. After tracing, the positive response rate was 72%; one patient had died. At the time of follow-up 31% of those traced had made a complete recovery and 25% still fulfilled diagnostic criteria for bulimia nervosa. Judged on behavioural symptoms 47.2% of responders had a 'good' outcome. Good outcome was associated with fewer social problems, higher social class, and a significant improvement in eating attitudes at follow-up. All outcome groups reported a reduction of interference by symptoms in other areas of life, and an improvement in mood state. No factors, including those described in previous studies, were identified which predicted outcome.

The TAPS project. 16: Difficult to place, long term psychiatric patients: risk factors for failure to resettle long stay patients in community facilities.

OBJECTIVE: To identify patients who could not be resettled in the community as part of the closure plans of two psychiatric hospitals and to determine their numbers and risk factors for failure. DESIGN AND SETTING: Prospective study of the closure of Friern and Claybury psychiatric hospitals. PATIENTS: The first third (369) of long stay psychiatric patients to be resettled. OUTCOME MEASURES: Reasons for patients being readmitted to hospital and not leaving the patients' service needs. RESULTS: 22--6% of both hospitals' long stay patients--were not successfully resettled in the community. Eighteen continuing care places per 100,000 of catchment area population seem to be required for this group. Patients whose placements were unsuccessful were usually readmitted because of a deterioration of their mental state and aggressive behaviour, both of which persisted and necessitated their continuing stay in hospital, often in a locked ward. Risk factors associated with failure were a high level of psychosis; a diagnosis of paranoid psychosis; incontinence; and being male. But having a social network, especially a large one, seemed to aid successful placement in the community. CONCLUSION: Rehabilitation efforts should be focused on the characteristics of these patients that put them at risk of failing to succeed in community placements.

The TAPS project. 17: Readmission to hospital for long term psychiatric patients after discharge to the community.

OBJECTIVE: To identify risk factors which increase the likelihood of readmission for long stay psychiatric patients after discharge from hospital. DESIGN: Follow up for five years of all long stay patients discharged from two large psychiatric hospitals to compare patients readmitted and not readmitted. SETTING: Friern and Claybury Hospitals in north London and their surrounding catchment areas. Most patients were discharged to staffed or unstaffed group homes. SUBJECTS: 357 psychiatric patients who had been in hospital for over one year, of whom 118 were "new" long stay and 239 "old" long stay patients. MAIN OUTCOME MEASURES: Readmission to hospital and length of subsequent stay. RESULTS: Of all discharged patients 97 (27%) were readmitted at some time during the follow up period, 57 (16%) in the first year after discharge, and 31 (9%) then remained in hospital for over a year. The best explanatory factors for readmission were: male sex, younger age group, high number of previous admissions, higher levels of symptomatic and social behavioural disturbance, a diagnosis of manic-depressive psychosis, and living in a non-staffed group home. CONCLUSIONS: During the closure of psychiatric hospitals, facilities need to be preserved for acute relapses among long term, and especially younger, discharged patients. Staffed group homes may help prevent relapse and reduce the number of admission beds required.

The TAPS Project. 4: An observational study of the social life of long-stay patients.

Observations of long-stay patients in a club in a psychiatric hospital were carried out unobtrusively over several months. Much of the social activity that went on was stimulated by an economy based around the purchase and exchange of tea and cigarettes, and the borrowing and lending of small change. Most patients could be fitted into one of four social categories: helpers, friends, nuisances, and the asocial. The inter-rater reliability of the observations was found to be 0.95. A close correspondence emerged between the observations of patients' social behaviour and material reported by patients when interviewed with the Social Network Schedule.

The TAPS Project. 5: The structure of social-network data obtained from long-stay patients.

The Social Network Schedule was successfully completed on 489 (64%) of 770 long-stay patients in Friern and Claybury Hospitals and the data on 3774 social contacts of the patients subjected to log-linear modelling. This showed that the category 'confidant' was salient in understanding the data. Latent-class analysis highlighted the importance of the nature of the social interaction between patients and their contacts. In particular, non-verbal exchanges of goods and services emerged as important in creating social bonds.

The TAPS project. 3: Predicting the community costs of closing psychiatric hospitals.

The planning of long-term care in the community as an alternative to in-patient care requires accurate information on the likely expense of altering the balance of provision. Unfortunately, as very few long-stay psychiatric hospitals have yet closed, the planning of these resource requirements has had to proceed in a vacuum. By examining the costs of community reprovision for the first 136 people to leave Claybury and Friern Hospitals, a prediction equation has been estimated from existing data which links the hospital-assessed characteristics (including psychiatric symptoms and behavioural problems) of these people to the subsequent cost of community care. About a third of the observed variation in these costs can be explained statistically by these 'baseline' characteristics. However, the first cohorts exhibit fewer behavioural problems and other symptoms of mental illness, they have been in hospital for shorter lengths of time, and they are younger. The prediction equation for the leavers is thus used to extrapolate community costs for those hospital residents yet to leave. It is found that community costs are lower than hospital costs, not just for the first cohorts of leavers, but for the full populations of the two hospitals scheduled to close.