Assessment of CD200R Activation in Combination with Doxycycline in a Model of Melioidosis.

Antimicrobial resistance continues to be a global issue. Pathogens, such as Burkholderia pseudomallei, have evolved mechanisms to efflux certain antibiotics and manipulate the host response. New treatment strategies are therefore required, such as a layered defense approach. Here, we demonstrate, using biosafety level 2 (BSL-2) and BSL-3 in vivo murine models, that combining the antibiotic doxycycline with an immunomodulatory drug that targets the CD200 axis is superior to antibiotic treatment in combination with an isotype control. CD200-Fc treatment alone significantly reduces bacterial burden in lung tissue in both the BSL-2 and BSL-3 models. When CD200-Fc treatment is combined with doxycycline to treat the acute BSL-3 model of melioidosis, there is a 50% increase in survival compared with relevant controls. This benefit is not due to increasing the area under the concentration-time curve (AUC) of the antibiotic, suggesting the immunomodulatory nature of CD200-Fc treatment is playing an important role by potentially controlling the overactive immune response seen with many lethal bacterial infections. IMPORTANCE Traditional treatments for infectious disease have focused on the use of antimicrobial compounds (e.g. antibiotics) that target the infecting organism. However, timely diagnosis and administration of antibiotics remain crucial to ensure efficacy of these treatments especially for the highly virulent biothreat organisms. The need for early antibiotic treatment, combined with the increasing emergence of antibiotic resistant bacteria, means that new therapeutic strategies are required for organisms that cause rapid, acute infections. Here, we show that a layered defense approach, where an immunomodulatory compound is combined with an antibiotic, is better than an antibiotic combined with a relevant isotype control following infection with the biothreat agent Burkholderia pseudomallei. This approach has the potential to be truly broad spectrum and since the strategy includes manipulation of the host response it's application could be used in the treatment of a wide range of diseases.

System-level change in mental health services in North Wales: An observational study using systems thinking.

PURPOSE: To describe changes to mental health services using systems thinking. METHOD: Structured standardized quality of life assessment (Manchester Short Quality of Life Assessment: MANSA) was used to establish service user priorities for changes to service provision (part of a process known as check in systems thinking). Current service performance in these priority areas was identified, and changes to service arrangements were planned, implemented and monitored by task and finish (T&F) groups (making use of a process known as flow in systems thinking). RESULTS: 81 MANSA assessments were completed at the check stage (by NM). Work finances and leisure activities emerged as service user priority areas for change, and T&F groups were established with representation of all sectors and service users. Ways to make improvements were observed, planned and implemented by T&F groups (the flow stage). CONCLUSION: The systems approach reveals how services and quality of life have been changed for patients in Wrexham. Further generalizable research is needed into the potential benefits of using systems thinking in mental health service evaluation.

Development of a social inclusion index to capture subjective and objective life domains (Phase II): psychometric development study.

OBJECTIVES: To produce a robust measure of social inclusion [Social and Community Opportunities Profile (SCOPE)] that is multidimensional and captures multiple life domains; incorporates objective and subjective indicators of inclusion; has sound psychometric properties including responsiveness; facilitates benchmark comparisons with normative general population and mental health samples [including common mental disorder (CMD) and severe mental illness groups]; can be used with people with mental health problems receiving support from mental health services or not; and can be used across a range of community service settings. DESIGN: Phase I: conceptual framework developed from a review of the literature and concept mapping. Phase II: questionnaire developed including UK national population surveys and other normative data. Pre-testing using cognitive appraisal and evaluation then pilot testing in a small convenience sample. Preliminary testing (following modification) in community (n = 252) and mental health service users (MHSUs) samples (n = 43). Data reduction including factor analysis and Mokken scaling for polytomous item response analysis then psychometric evaluation, including internal consistency and discriminant and construct validity. Test-retest reliability assessed in a convenience sample of students (n = 119). Final testing in clinical services including psychometric evaluation and responsiveness testing. SETTING: The community sample was set in participants' households across the UK. The MHSU sample was set in a south Wales resource centre. The student sample was set in a university. PARTICIPANTS: The community sample was randomly selected from the postal address file in five areas in England and Wales. Forty people in this sample were subgrouped as having a CMD based on their responses to the Mental Health Index five items. Two MHSU samples were obtained from existing services. RESULTS: Psychometric testing on the field data from the SCOPE long version demonstrated good internal consistency of all scales (alpha ≥ 0.7), good construct validity, with SCOPE scales correlating highly with each other sharing between 40% and 61% of variance and a close but lesser association with community participation and social capital. Chi-squared tests on objective items and analysis of variance between groups on SCOPE scales demonstrated good discriminant validity between different mental health groups (and better than the Mokken scaling results). Acceptability was good, with 77% of the service user sample finding the SCOPE domains relevant. The number of items in SCOPE decreased from 121 to 48 following data reduction. Scales in the short version of SCOPE retained reasonable internal consistency (alpha between 0.60 and 0.75). Test-retest reliability demonstrated reliability over time, with strong associations between all items over a 2-week period. Repeating the discriminant validity tests on the short version demonstrates good discriminant validity between the mental health groups. Acceptability improved, with 90% of the sample describing questions as relevant to them. CONCLUSIONS: The main aim of producing an instrument with good psychometric properties for use in research and clinical settings, namely the SCOPE short version, was achieved. Ongoing data collection will enable responsiveness testing in the future. Further research is needed including larger samples of minority and disadvantaged groups, including those with physical illnesses and disabilities, and specific mental health diagnostic groups. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Integrating health and social care in community mental health teams in the UK: a study of assessments and eligibility criteria in England.

The purpose of this cross-sectional survey was to examine the relationship between assessments and eligibility decisions made by health and social care staff in multidisciplinary community teams in England. The data were collected between December 2004 and August 2005. The study was a replication of a study that took place in the same eight locations in England before the modernization of health and social care by the present government. Four hundred and thirteen care coordinators responded from 71 teams to produce a total of 1481 clients. Sixty per cent (n = 884) of the sample of clients were categorised as having a psychotic illness compared to 63% in 1997 to 1998. Fair Access to Care Services (FACS) criteria determine access to social care services, and the Care Programme Approach (CPA) determines the level of mental health services provided. There was a close but an incomplete association between FACS and CPA judgements (kappa = 0.37; 95% confidence interval 0.31-0.43). Compared to the standardised Matching Resources to Care version 2 indication of complex needs, social workers' judgements were the most closely aligned to FACS judgements (F = 5.80; d.f. = 2 and 1203; P < 0.01). This raises the question of the need for training for health professionals in order to make decisions about social assessment and eligibility determination.

Fair Access to Care Services (FACS): implementation in the mental health context of the UK.

Since April 2003, all adults requiring social care services must have an assessment to determine their eligibility, which is set within the four-level framework of Fair Access to Care Services [FACS; LAC (2002)13]. This paper examines the implementation of FACS by community mental health teams in eight sites in mental health partnership trusts, and one in a mental health and social care trust in the UK. Twenty-eight respondents (managers within trusts and social services departments) participated in in-depth qualitative interviews, which were undertaken between August 2004 and February 2005. The interviews covered: consultation with users and partner organisations; training and briefings for staff; FACS thresholds; integration of FACS and the Care Programme Approach; and the impact of implementing FACS on budgetary arrangements between health and social care. Using the framework analysis approach to analyse data, it was found that FACS implementation in mental health services has been somewhat haphazard, and has identified real differences between health and social care approaches to eligibility determination, assessment and priorities. In particular, the type and amount of consultation, training and induction into FACS was variable, and in some cases, unacceptably poor. While FACS may have reduced variability between authorities, the exercise of professional judgement in the operation of FACS and the lack of high-quality preventative services remain as potential sources of inequity within the system. The authors conclude that FACS has revealed and reinforced a growing separation rather than an integration of mental health and social care ideas and practices, at least in the participating sites.

'They're all depressed, aren't they?' A qualitative study of social care workers and depression in older adults.

Statutory and voluntary social services provide care and support for vast numbers of vulnerable older adults, yet little is known about how social care practitioners respond to depression in this high risk population. This study elicited the perceptions and conceptualizations of this condition among social care staff, and views on how the response of social care and other agencies might be improved. Qualitative interviews were conducted with 20 social care practitioners working in generic services for older adults in south London. Depression was perceived to be remarkably common among clients, a phenomenon largely attributed to the adverse circumstances of old age, particularly social isolation. A key message from participants was that social causes indicate a need for social interventions. While primary care was criticised for not taking depression seriously in older people, mental health services were generally praised. Expansion of social, recreational and psychological interventions was advocated.

Reducing psychiatric stigma and discrimination--evaluating an educational intervention with the police force in England.

BACKGROUND: Across the world there are programmes challenging negative stereotypes of people with mental health problems and associated discriminatory behaviours, but the evidence base describing what works in practice is still underdeveloped. This paper evaluates the effectiveness of a mental health training intervention with the police force in England. METHOD: A total of 109 police officers attended training workshops and completed pre- and post-questionnaires detailing knowledge, attitudes and behavioural interventions. RESULTS: Mean attitude scores fell from 2.4 at baseline to 2.3 at follow-up (p < 0.0001) using a 5-point Likert scale. Five key message statements were assessed - 70 % of cases successfully reported more messages at follow-up as compared to baseline; however, the stereotype linking people with mental health problems with violent behaviour overall was not successfully challenged. Positive impacts on police work, particularly improvements in communication between officers and subjects, were reported by a third of cases. CONCLUSIONS: Short educational interventions can produce changes in participants' reported attitudes towards people with mental health problems, and can leave police officers feeling more informed and more confident to support people in mental distress.

Evaluating the impact of a locality based social policy intervention on mental health: conceptual and methodological issues.

Urban regeneration initiatives provide an opportunity for examining the impact of changes in socio-economic circumstances on the mental health of different groups and individuals within localities. This paper sets out the conceptual and methodological bases for evaluating the impact of a population based social policy intervention on mental health. We suggest the need to integrate a range of disciplinary and methodological developments in research on health inequalities in exploring the impact of urban regeneration on mental health. A combination of multi-level modelling, subjective indicators and narrative accounts of individuals about mental health in the context of locality and personal changes are central for developing theories and methods appropriate for exploring the action and interaction of effects operating between structural and individual/agency levels.

Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care.

UNLABELLED: ***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS*** BACKGROUND: Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. OBJECTIVE: The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format. RESULTS: Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%). CONCLUSIONS: Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS*** BACKGROUND: People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective. OBJECTIVES: The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions). METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score. RESULTS: Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT. CONCLUSIONS: The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS*** BACKGROUND: This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic. OBJECTIVES: There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data. RESULTS: There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs. (ABSTRACT TRUNCATED)

Quality of life outcome in a randomized controlled trial of case management.

BACKGROUND: This paper presents the quality of life (QOL) outcome results from the UK700 randomised controlled trial of case management. METHOD: A total of 708 patients with severe mental illness were randomly assigned to intensive and standard forms of case management in four sites in the UK. QOL was assessed using the Lancashire Quality of Life Profile, which provides a self-reported objective and subjective appraisal of eight life domains (finances, work, leisure, family, social relations, living situation, safety and health). The outcome after 2 years was examined using univariate and multivariate analyses. RESULTS: Significant improvements in QOL over the 2 years were observed. The QOL outcome did not differ significantly by case management treatment conditions or by diagnosis. A better outcome was associated with improvements in depression and with the location (site) of treatment. In one site there were significant improvements in all eight domains and overall QOL, with moderate or better effect sizes (> 0.4) in three domains and overall QOL. CONCLUSIONS: Depression should be assessed when subjective QOL measures are used. Better means for describing service organisations and the context/place in which they operate should be developed in order to explain more of the variance in QOL outcomes.

Vocational rehabilitation for people with severe mental illness.

BACKGROUND: Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective. OBJECTIVES: To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention. SEARCH STRATEGY: Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies. SELECTION CRITERIA: Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness. DATA COLLECTION AND ANALYSIS: Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials. MAIN RESULTS: Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care. REVIEWER'S CONCLUSIONS: Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.

The Lancashire Quality of Life Profile: modification and psychometric evaluation.

BACKGROUND: Although widely used in Europe, the conceptual and psychometric qualities of the Lancashire Quality of Life Profile (LQoLP) have not been thoroughly examined. Four issues need attention: coverage, scale construction, systematic missing data, and psychometric properties. METHOD: Concept mapping was used to examine the coverage, and exploratory factor analysis to examine the empirical scale structure of the LQoLP. Data of 518 long-term patients from ten different mental health care settings were used. Modifications to the LQoLP were proposed on the basis of these findings, and its psychometric properties were tested. Thirty-one respondents participated in a test-retest reliability study (T1-T2: 2 weeks). RESULTS: The modified LQoLP covers the quality of life-concept in a more comprehensive manner. Internal consistency, test-retest reliability and validity are good. CONCLUSIONS: The modified version of the LQoLP now covers ten domains, paying specific attention to patients' definition of quality of life (autonomy, coping, self-worth). Domains are now based on factor analysis. The problem of systematic missing data is solved. Psychometric properties are good. Because of moderate alphas, two domains need further investigation.

Helping people with severe mental illness to obtain work: systematic review.

OBJECTIVE: To determine the most effective way of helping people with severe mental illness to obtain competitive employment-that is, a job paid at the market rate, and for which anyone can apply. DESIGN: Systematic review. PARTICIPANTS: Eligible studies were randomised controlled trials comparing prevocational training or supported employment (for people with severe mental illness) with each other or with standard community care. OUTCOME MEASURES: The primary outcome was number of subjects in competitive employment. Secondary outcomes were other employment outcomes, clinical outcomes, and costs. RESULTS: Eleven trials met the inclusion criteria. Five (1204 subjects) compared prevocational training with standard community care, one (256 subjects) compared supported employment with standard community care, and five (484 subjects) compared supported employment with prevocational training. Subjects in supported employment were more likely to be in competitive employment than those who received prevocational training at 4, 6, 9, 12, 15, and 18 months (for example, 34% v 12% at 12 months; number needed to treat 4.45, 95% confidence interval 3.37 to 6.59). This effect was still present, although at a reduced level, after a sensitivity analysis that retained only the highest quality trials (31% v 12%; 5.3, 3.6 to 10.4). People in supported employment earned more and worked more hours per month than those who had had prevocational training. CONCLUSION: Supported employment is more effective than prevocational training at helping people with severe mental illness obtain competitive employment.

Managing severe mental illness in the community using the Mental Health Act 1983: a comparison of Supervised Discharge and Guardianship in England.

BACKGROUND: Two measures in the English Mental Health Act allow requirements to be imposed upon patients living in the community. These are Guardianship (Section 7) and Supervised Discharge (Section 25A). AIMS: The paper aims to compare patients with mental illnesses, made subject to Guardianship or Supervised Discharge. METHOD: Data on patient characteristics, impairment, needs and interventions were collected from keyworkers in a random national sample of Trusts and local authorities. Ratings were obtained on standardised measures of disability, impairment and needs. RESULTS: Patients placed on Supervised Discharge were more likely to have problems of treatment compliance and drug misuse, whilst those on Guardianship were more likely to have problems of social welfare and higher ratings of disability and impairment. Supervised Discharge has a higher proportion of African-Caribbean patients. Interventions delivered are rated as effective for both measures. CONCLUSIONS: Legal changes proposed in England include a single power for supervision in the community. This should not mean a focus on risk management to the neglect of social welfare interventions.

Matching resources to care: the acceptability, validity and inter-rater reliability of a new instrument to assess severe mental illness (MARC-1).

BACKGROUND: Most definitions of severe mental illness (SMI) are categorical and assign the patient to either SMI or not-SMI status. While this is useful for some purposes, it is a rather limited approach. The purpose of the present study is to develop a new method of addressing the issue of 'severity', and to develop a dimensional rather than a categorical approach. The paper reports on the acceptability, reliability and validity of a method developed to collect a standard set of data covering the majority of items specified in the academic and policy literature as characterising SMI. METHOD: A single page form, Matching Resources to Care (MARC-1), containing most of the items used in definitions of SMI was used to collect data from community mental health staff about their current open caseload, in four co-terminous health and social services settings during a census week (n = 2139). In addition to the data from the four pilot sites, we conducted a substudy (n = 91), in which two raters rated the same cases during the same week. RESULTS: The MARC-1 scores were able to distinguish between patients in receipt, and those not in receipt, of specific types of community care (level of care, eligibility for care and statutory aftercare) (P < 0.001). The MARC-1 score was modestly but significantly correlated (r = 0.28) with the Global Assessment Scale (P < 0.001). The mean percentage inter-rater agreement for the MARC-1 score items was 87%. CONCLUSION: It is possible to use a simple census form in both health and social services agencies. The completion rates were good in both services. The levels of reliability were good, and concurrent validity was established with specific types of care in the community.

A new version of the geriatric depression scale for nursing and residential home populations: the geriatric depression scale (residential) (GDS-12R).

The objective was to develop a new short-form Geriatric Depression Scale (GDS-12R) suitable for older people living in nursing and residential care settings, including those persons with significant cognitive impairment. A total of 308 newly admitted residents of 30 nursing and residential homes in northwest England were interviewed using the Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination, and the Affect Balance Scale (ABS). A 12-item version of the GDS was shown to have greater internal reliability than the 15-item version, because of the context-dependent nature of the deleted items. There was close agreement between the GDS-12R items and another indicator of depressed mood (a single item from the ABS). Furthermore, moderate to high levels of cognitive impairment did not affect the performance of the new version of the scale. The GDS-12R provides researchers and clinicians with a brief, easy-to-administer depression scale that is relevant to residential and nursing home populations.

Dependency in older people recently admitted to care homes.

OBJECTIVE: to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care. METHOD: we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication. RESULTS: 50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder. DISCUSSION: the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.

Recognition of depression by staff in nursing and residential homes.

Newly admitted residents in long-term care facilities are particularly vulnerable to depression and the early recognition and treatment of depression is therefore crucial around the time of admission to a home. Staff from 30 nursing and residential homes were asked to assess newly admitted residents for depression using HoNOS 65+ and their responses were compared with residents' scores on the Geriatric Depression Scale (GDS-15). The findings indicated low levels of recognition by staff, with rates ranging from 15% to 27% of those identified as depressed, depending on the definition of depression used. There was no statistically significant difference in the rate of recognition between nursing staff and other care staff. A staff survey conducted in the 30 study homes indicated that fewer than 2% had received specific in-service training on depression in older people. The findings suggest that more needs to be done to raise staff awareness of depression in residents of nursing and residential homes, particularly in newly admitted residents.

A comparison of the quality of life of severely mentally ill people in UK & German samples.

The improvement of the quality of life of people with a severe mental illness is a key policy objective and an important outcome for clinical services. Drawing on cases assessed using the Lancashire Quality of Life Profile and its German translation (The Berliner Lebensqualitatprofil), this paper explores the relationship between personal characteristics, objective well being, subjective well being and overall well being. These variables are compared in two large data sets of people with severe mental illness, one from the UK (n = 1279) and the other from Germany (n = 386). The comparison shows that UK cases have significantly lower subjective well-being in almost all life domains (except safety, living situation and employment). UK cases reported slightly but not significantly higher levels of satisfaction with employment but German cases are more often employed than their UK counterparts. The German samples reported substantially better subjective well-being ratings for health, finances, family, leisure and social life. Exploration of the predictors of overall well-being shows that in both countries depression has the effect of reducing subjective well-being scores, except in relation to work (both samples), religion (UK), finance and safety (Germany). Regression analysis confirms that age, depression and objective circumstances make a small contribution to overall well-being but that subjective ratings in individual life domains make the major contribution. The most important individual predictors of overall well-being for the two samples combined include being a victim of crime, depression and satisfaction with leisure, work, health and mental health, family, living situation, finance and social contacts. Factor analysis indicates that the variance in global well-being explained in both samples combined is 36% (31% in the German samples and 38% in the UK sample).