Whole Life: a feasibility study of a recovery-focussed intervention in patients with stabilised schizophrenia [version 2; peer review: 2 approved, 1 approved with reservations].

Background: The Recovery Approach is about supporting people to live the best life they possibly can. This paper reports on a 2008-11 study of a recovery-focussed, one-to-one coaching programme called Whole Life (WL) in a group of people with stabilised schizophrenia. WL comprises 15 modules, each addressing an aspect of life that may pose challenges for someone with mental illness. It involves regular meetings with a coach, additional homework activities and lasts approximately one-year. This level of commitment requires participants to be motivated and enthusiastic. Methods: This was a non-randomised feasibility study, designed to assess acceptability and potential benefits of WL. The WL group was compared to another group of people with the same diagnosis, who received their usual treatment. This was not a strict control group. The primary outcome measure was the Social Adaptation Self-Assessment Scale. Results: Of those recruited to the WL group, 33/44 (75%) completed the full programme. WL participants showed an 11-point increase in mean SASS between baseline and Week 60. Subjective ratings showed benefits of WL at 3 and 6 months after the intervention had ceased, with most saying they felt better and none saying that they felt worse. The comparison group was more ill than the WL group at baseline and showed some improvement over the course of the study, albeit at a lower level than the WL group. However, controlling for baseline group differences meant that none of the outcome measures could reliably distinguish between WL and comparison groups. Conclusions: The study showed that WL is an acceptable and helpful intervention for motivated and enthusiastic individuals. It may have wider applicability for people with a less serious and chronic mental illness, although we do not know how it compares to other interventions. We discuss some methodological limitations of the study.

To admit or not to admit? The effect of framing on risk assessment decision making in psychiatrists.

BACKGROUND: The way that information is presented is well known to induce a range of biases in human decision tasks. Little research exists on framing effects in psychiatric decision making, but it is reasonable to assume that psychiatrists are not immune and, if so, there may be implications for the welfare of patients, staff and the general public. AIMS: To investigate whether presentation of risk information in different formats (frequency, percentage and semantic) influences inpatient admission decisions by psychiatrists. METHODS: Six-hundred seventy-eight general adult psychiatrists read a short clinical vignette presenting a case scenario of a patient presenting for inpatient admission. One of four condition questions followed the vignette, incorporating either numerical or percentage probabilities and the semantic labels "high" and "low" risk. In each condition, the actual risk was identical, but the way it was presented varied. The decision to admit the patient or not was recorded and compared across conditions. RESULTS: More individuals chose to admit the patient when risk information was presented in numerical form (X2 = 7.43, p = 0.006) and with the semantic label "high" (X2 = 7.27, p = 0.007). CONCLUSIONS: Presentation of risk information may influence decision making in psychiatrists. This has important implications for mental health clinical practice where clinicians are required to interpret probabilistic information within their daily work.

The effect of single-sex wards in mental health.

BACKGROUND: The need for single-sex accommodation in mental health trusts has been widely expressed in documents from the NHS Executive and in national and local policies. This case study describes the effects of changing two mixed-sex wards into single-sex wards. METHODS: Two mixed-sex inpatient wards were reorganised into two single-sex wards. Qualitative data on staff views was gained from semi-structured interviews and collected. RESULTS: Staff and patients appear to have made the transition from mixed to single-sex wards with relatively few problems. Staff described differences emerging between the male and female wards, with the male ward becoming calmer, while the female ward became more disruptive. CONCLUSIONS: Overall, the implementation was successful. We suggest that in general single-sex wards are just as effective as mixed-sex wards and, in some respects, may be better.

Equations for converting scores between depression scales (MÅDRS, SRS, PHQ-9 and BDI-II): good statistical, but weak idiographic, validity.

BACKGROUND: A variety of depression rating scales are currently used in clinical and research practice. As these scales are generally thought to correlate well, there may be some benefit in deriving equations to translate the score on one scale to that on another. METHOD: Using pairwise ratings, we compared the Montgomery-Åsberg Depression Rating Scale (MÅDRS), Beck Depression Inventory II (BDI-II), Patient Health Questionnaire (PHQ-9) and Zung Self Rated Scale (SRS). The primary comparisons of interest were as follows: PHQ-9 and MÅDRS, PHQ-9 and BDI-II, SRS and MÅDRS, and SRS and PHQ-9. One hundred and fifty pairs of ratings were collected for each of these four comparisons, and these were used in a regression analysis to generate a predictive equation between scale pairs. The predictive equations were then tested for accuracy by using novel data. RESULTS: There was a reasonably strong correlation between scales. Simple regression equations describe the relationships between certain permutations of the BDI-II, PHQ-9, SRS and MÅDRS well enough to allow the score on one scale to be estimated from the score on another. On average, the equations work well. However, when used to predict individual cases, they often fail. CONCLUSION: It does appear that conversion equations for depression scores are precise enough to be of use when applied to averages; these might aid comparison of data across different studies, meta-analysis or instrument selection for clinical trials. But regarding scale translation at the idiographic level, the variability we have observed is so great that severe doubt is cast on the validity of such an approach.

Classification of risk in psychiatry.

Psychiatric risk-assessments generally quantify risk using broad, categorical, indicators (e.g., high-risk, low-risk). We examined reliability of such indicators when applied by mental-health professionals. Four versions of a questionnaire were used, each specifying a different clinical outcome along with a range of different probabilities at which that outcome might occur. Respondents classified each probability, allowing a comparison of the level of likelihood at which different professionals would apply the terms 'high-risk', 'medium-risk' and 'low-risk'. We found little consistency among professionals who assessed risk for the same outcomes. Moreover, there were also large and unpredicted differences in response-profiles between the 4 clinical outcomes. These findings raise concerns about the communication value of current risk-assessment terminology.

Risk assessment in mental health: staff attitudes and an estimate of time cost.

BACKGROUND: Risk assessment is a routine part of mental health services, with professionals being required to complete a risk assessment proforma (RAP) for every patient under their care. AIMS: This study was designed to investigate staff attitudes to, and beliefs about, the completion of risk assessment paperwork. METHOD: We surveyed 300 professionals across one county to examine: (i) the amount of time taken to complete RAPs; (ii) attitudes towards completing such paperwork; and (iii) beliefs about the quality and usefulness of the information recorded. RESULTS: We found considerable variation in the amount of time taken to complete RAPs. The median time was 18 minutes with doctors spending significantly less time than nurses. More favourable attitudes towards RAPs were seen in nurses than in doctors, in spite of the increased time spent completing them. Moreover, nurses also held more positive views about the value and benefit of the information recorded in RAPs. CONCLUSIONS: The findings suggest that RAP completion may account for a significant proportion of staff time. Inter-professional differences in belief and attitude were prominent and this should be an important consideration in the evolution of risk assessment procedures.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: reasons for switching and safety.

OBJECTIVE: An international, non-randomised study evaluated efficacy and safety of risperidone long-acting injectable (RLAI) compared to previous treatment. To investigate generizability of the European data set to the UK subset safety and switching data are reported here. METHODS: Patients with schizophrenia or other psychotic disorder, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months. RESULTS: Of 182 UK patients enrolled, 79% had schizophrenia, 21% other psychotic disorders. Insufficient efficacy (43%), side effects (45%), and non-compliance (25%) were the most common reasons for switching. Sixty-nine per cent of patients completed the trial; 8% discontinued due to adverse events (AEs). Most frequent treatment-emergent AEs were headache (8.2%), relapse (7.7%) and insomnia (7.1%); 8 (4.4%) patients reported injection-related AEs. There were significant improvements in extrapyramidal symptom rating scale total and subscale (particularly Parkinsonism) scores, regardless of previous medication (total cohort, p < or = 0.0001). There was a small but significant increase in body weight at endpoint (1.2 kg, p = 0.0023). One patient suffered a myocardial infarction and died (not treatment-related). There were no substantial differences between the full data set and the UK sub-population CONCLUSION: Switch to RLAI was well-tolerated in stable patients over 6 months. The European data set is generalizable to the UK patient population.

Excessive daytime sleepiness in psychiatric disorders: Prevalence, correlates and clinical significance.

This study examined the prevalence of excessive daytime sleepiness, as measured by the Epworth Sleepiness Scale (ESS), in a cohort of adult psychiatric patients. A total of 300 psychiatric outpatients and an additional 300 healthy controls completed the ESS. Excessive sleepiness was defined by a score of > or =10. The prevalence of excessive daytime sleepiness was higher in the psychiatric group (34%) than the control group (27%), and the mean ESS score was also significantly higher in the psychiatric group. The prevalence of excessive sleepiness was higher for female psychiatric patients, but this pattern was not found in the control group. Surprisingly, there was no difference in ESS score between patients taking antipsychotic medication and those not taking antipsychotic medication. The data suggest that excessive daytime sleepiness is a significant issue in general adult psychiatry, but this must be interpreted against a relatively high prevalence in the normal population.

Sideline skin and wound care for acute injuries.

The management of acute skin trauma in sports is reviewed from the perspective of the sideline medical provider. Skin injuries covered in this article include abrasions, lacerations, blisters, chafing, and sunburn. Sideline evaluations, treatment techniques, recommended equipment, and prevention are discussed. A well-equipped and prepared sideline provider can have a great impact on the proper care of acute sports skin injury and more rapid return to play.

Sideline management of facial injuries.

Physicians who cover sporting events frequently encounter facial injuries. These injuries include contusions, hematomas, abrasions, lacerations, ruptured tympanic membranes, and fractures. For most physicians covering events, the diagnoses and decisions on returning athletes to play must be made without many of the diagnostic tools available in the office, such as radiographs, nasopharyngoscopes, or CT scans. As a result, physicians must rely on focused histories and thorough physical examinations to make their diagnoses and ultimately determine if injured participants can continue in their respective events.

Are placebo-controlled trials still important for obsessive compulsive disorder?

The use of placebos as reference agents in randomised controlled trials for psychiatric disorders has come under question for ethical reasons. Alternative methods for validating the efficacy of new treatments exist, but may not be as reliable as placebo. In this paper we examine arguments for and against the ongoing use of placebo agents in the development of new treatments for obsessive compulsive disorder in the context of evidence from randomised controlled trials.

Excessive daytime sleepiness in psychiatry: a relevant focus for clinical attention and treatment?

Excessive daytime sleepiness is a feature of many general medical disorders and is associated with significant impairment in function and well-being. It has, however, received little attention in psychiatry although it may be a common and clinically important problem. The opinions of two expert groups, and a survey of the literature, were used to form views about the prevalence and clinical significance of excessive sleepiness in psychiatric populations. Issues relating to pharmacological treatment were also considered. Despite a scant evidence base, the conclusions are that excessive sleepiness may be a common and significant problem, and potentially amenable to treatment. However, clinician awareness is probably limited and there are opportunities for further research.

Case histories illustrating the utility of sertindole in clinical practice.

Many conventional and atypical antipsychotic agents are available for the treatment of schizophrenia. Matching individual patients to the medication that suits them best is often a matter of trial and error. Controlled clinical trials and extensive post-marketing research have shown that the atypical antipsychotic agent sertindole is a broadly efficacious and safe choice for the treatment of schizophrenia. Individual case reports emerging from the ongoing sertindole post-marketing clinical programme illustrate how, under normal conditions of clinical practice, a switch to sertindole can benefit patients who have, for various reasons, previously not been satisfactorily managed on conventional or other atypical antipsychotic agents. Such case reports have shown that a switch to sertindole has the potential to provide greater relief from positive, negative and affective symptoms than has been achieved with conventional and certain other atypical agents. Cognitive dysfunction evident during therapy with conventional antipsychotic agents has also been seen to improve in individuals switched to sertindole. These improvements have occurred without evidence of extrapyramidal symptoms or other poorly tolerated adverse events. After switching to sertindole, the five patients described in this report complied well with therapy, were generally able to perform daily activities more efficiently, and also had improved personal relationships and vocational potential, all of which contributed to improvements in their overall quality of life.

Nurses' Observation Scale for Inpatient Evaluation: reliability update.

BACKGROUND: The Nurses' Observation Scale for Inpatient Evaluation is a 30-item scale designed in 1965 for behavioural and observational rating of psychiatric inpatients. AIM: This paper reports a re-evaluation of the Nurses' Observation Scale for Inpatient Evaluation carried out to confirm that it remains reliable in a modern United Kingdom (UK) setting. METHOD: The scale is a joint-rated one and we tested the degree of agreement between two individual raters and not, as in previous studies, between two pairs of raters. A total of 100 patients were each rated by two nurses, and a least-squares simple regression model was used to describe the average level of agreement between the pairs of ratings. RESULTS: The correlation in total scale scores was 0.76 (F = 136, P < 0.0001). The correlations for Negative and Positive Factors were 0.68 (P < 0.001) and 0.75 (P < 0.001), respectively. CONCLUSION: This study has shown that the Nurses' Observation Scale for Inpatient Evaluation retains satisfactory inter-rater reliability with current clinical populations, and we suggest that it remains a useful tool for everyday clinical practice and a basis for meaningful communication between staff about patient status.

Diagnosing and treating depression in general hospitals.

Depressive conditions are common in general hospital patients but if recognized can be treated by both pharmacotherapeutic and psychotherapeutic means. Although hospital doctors cannot be expected to be masters of the intricacies of treating depression, they can make the diagnosis and prescribe first-line antidepressants to the benefit of most cases.

Physician prescribing patterns of oral corticosteroids for musculoskeletal injuries.

BACKGROUND: There is considerable controversy as to when and if oral corticosteroids are indicated for musculoskeletal injury. Although the perception is that sports medicine physicians prescribe oral corticosteroids frequently, there is no documentation of this behavior in the literature. The purpose of this study was to obtain a description of the corticosteroid-prescribing patterns of primary care sports medicine physicians and look for common indications. METHODS: A two-page questionnaire was included in the registration packets of 195 physicians at a national sports medicine conference. RESULTS: Ninety-nine questionnaires were returned. Fifty-eight (58.6%) of the physicians reported prescribing oral corticosteroids for musculoskeletal injuries. Physicians who prescribed corticosteroids for injuries averaged 6.6 prescriptions per month. Prednisone was the corticosteroid prescribed by 82% of physicians. The average prescription length was 7 days. One half of the physicians (51.7%) tapered the dose. The most common starting dose (mode) was 60 mg. CONCLUSIONS: Despite little evidence to support their use, primary care sports medicine physicians commonly prescribe corticosteroids.