Offenders with intellectual disabilities in prison: what happens when they leave?

BACKGROUND: People with intellectual disabilities, if convicted of offences, may be sentenced to prison, but little is known about their life when they are released. METHOD: This study followed up men with intellectual disabilities who were leaving prisons in England. RESULTS: The men were hard to contact, but 38 men were interviewed, on average 10 weeks after leaving prison. The men were living in a variety of situations and often were very under-occupied, with limited social networks. A total of 70% were above the clinical cut-off for anxiety, and 59.5% were above the clinical cut-off for depression. The men were receiving little support in the community, and many had been reinterviewed by police. CONCLUSIONS: Community teams need to provide better support to this very vulnerable group.

Quality of Life and Quality of Support for People with Severe Intellectual Disability and Complex Needs.

BACKGROUND: People with severe and profound intellectual disabilities often spend substantial time isolated and disengaged. The nature and quality of the support appears to be important in determining quality of life. METHODS: Structured observations and staff questionnaires were used to explore the quality of life and quality of support for 110 people with severe and profound disabilities and complex needs. RESULTS: On average, people spent approximately 40% of their time engaged in meaningful activities, received contact from staff 25% of the time (6% in the form of assistance to be engaged). Just over one-third received consistently good active support, which was associated with other measures of quality of support and emerged as the strongest predictor of outcomes. CONCLUSIONS: Quality of life and quality of support were relatively poor, although with about one-third of people receiving skilled support. Consistently good active support was the best predictor of outcome and proposed as a good indicator of skilled support.

Methodological considerations in service use assessment for children and youth with mental health conditions; issues for economic evaluation.

Economic evaluations are increasingly used in decision-making. Accurate measurement of service use is critical to economic evaluation. This qualitative study, based on expert interviews, aims to identify best approaches to service use measurement for child mental health conditions, and to identify problems in current methods. Results suggest considerable agreement on strengths (e.g., availability of accurate instruments to measure service use) and weaknesses, (e.g., lack of unit prices for services outside the health sector) or alternative approaches to service use measurement. Experts also identified some unresolved problems, for example the lack of uniform definitions for some mental health services.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery.

BACKGROUND: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. AIMS: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. METHOD: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined. RESULTS: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive. CONCLUSIONS: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

The costs of key worker support for disabled children and their families.

BACKGROUND: Key workers provide a single point of contact for disabled children and their families, supporting them and facilitating access to other services. Key worker services appear to generate good outcomes for families and provision is encouraged through central government policy. Recent increases in key worker provision have been accompanied by a proliferation of delivery models yet there is very little information on their costs. METHODS: Within a study identifying which service characteristics generate good outcomes for families, unit costs for seven key worker services were estimated. Informed by economic theory, the estimates drew on data from managers, finance departments and other publicly available sources. Data on the frequency and duration of contact with key workers were obtained from families and combined with the service-specific unit costs to arrive at the contact cost per family. The variations in the costs of supporting families were explored. RESULTS: On average, key worker contact with disabled children and their families cost pound 151 over a 3-month period. Contact costs were found to vary with the level of the child's disability and the number of role aspects that key workers performed. This latter variable was associated with improved outcomes. CONCLUSION: The low response rate to the questionnaire and absence of data on the costs of other elements of the families' support packages may limit generalization from this study. Even so, such findings can help inform managers and planners about allocation of their scarce resources. Good-quality services appear to cost more but the relationship between cost, quality and outcomes is not a simple one.

Assessing services, supports and costs for young families under stress.

BACKGROUND: Despite the attention paid to family support services in legislation and guidance, there is still relatively little evidence on which to base the development of effective services, and even less on the costs and cost-effectiveness of different models of support. METHODS: The study designed and examined the practical feasibility of a methodology for collecting service use data and other information on families. Unit costs of services were calculated and data were collected in interviews with 177 young families under stress in Northern Ireland and South-East England. Service use patterns and costs were analysed. RESULTS: Comparisons showed that families made greater use than the general population of many services. There were marked variations within the sample in the patterns of service use and costs, to some extent reflecting differences in the needs of the young families. DISCUSSION: The methods developed for collecting service use data, calculating unit costs and estimating costs for families were feasible.

Key worker services for disabled children: what characteristics of services lead to better outcomes for children and families?

BACKGROUND: Research has shown that families of disabled children who have a key worker benefit from this service and recent policy initiatives emphasize the importance of such services. However, research is lacking on which characteristics of key worker schemes for disabled children are related to better outcomes for families. METHODS: A postal questionnaire was completed by 189 parents with disabled children who were receiving a service in seven key worker schemes in England and Wales. Path analysis was used to investigate associations between characteristics of the services and outcomes for families (satisfaction with the service, impact of key worker on quality of life, parent unmet need, child unmet need). RESULTS: The four path models showed that key workers carrying out more aspects of the key worker role, appropriate amounts of contact with key workers, regular training, supervision and peer support for key workers, and having a dedicated service manager and a clear job description for key workers were associated with better outcomes for families. Characteristics of services had only a small impact on child unmet need, suggesting that other aspects of services were affecting child unmet need. CONCLUSIONS: Implications for policy and practice are discussed, including the need for regular training, supervision and peer support for key workers and negotiated time and resources for them to carry out the role. These influence the extent to which key workers carry out all aspects of the key worker's role and their amount of contact with families, which in turn impact on outcomes.

A randomized controlled trial to evaluate the effectiveness and cost-effectiveness of psychodynamic counselling for general practice patients with chronic depression.

BACKGROUND: Counsellors have been employed in general practice with little evidence of effectiveness. This study examined the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression either alone or combined with anxiety. METHOD: A randomized controlled trial with an economic evaluation was carried out in Derbyshire. One hundred and forty-five patients were recruited at seven GP practices by screening using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression, anxiety and other mental health symptoms, social and interpersonal functioning and social support were measured at baseline, 6 months and 12 months. Comprehensive costs were also estimated. RESULTS: There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6 or 12 months. However fewer experimental group patients were still 'cases' on the BDI than controls at 12 months. There were no significant differences in the mean total costs, aggregate costs of services, or any service-group costs except for primary care, between the experimental and control groups over time. CONCLUSIONS: This trial demonstrates only very limited evidence of improved outcomes in those referred to counselling and increased primary care treatment costs in the short-term. Stricter referral criteria to exclude the more severely depressed in the group (BDI > or = 24) might have yielded more conclusive results.

Grassland-herbivore interactions: how do grazers coexist?

We develop a new approach to modeling grazing systems that links foraging characteristics (intake and digestive constraints) with resource dynamics via the probability of encounter with different grass heights. Three complementary models are presented: the generation of a grass height structure through selective grazing; investigating the conditions for consumer coexistence; and, using a simplified resource structure, the consequences for consumer abundance. The main finding is that coexistence between grazers differing in body size is possible if a single-resource type becomes differentiated in its height structure. Large grazers can facilitate food availability for smaller species but with the latter being competitively dominant. The relative preference given to different resource partitions is important in determining the nature of population interactions. Large-body and small-body grazer populations can interact through competitive, parasitic, commensalist, or amensalist relationships, depending on the way they partition the resource as well as their relative populations and the dynamics of resource renewal. The models provide new concepts of multispecies carrying capacity (stock equilibrium) in grazed systems with implications for conservation and management. We conclude that consumer species are not substitutable; therefore, the use of rangeland management concepts such as "livestock units" may be inappropriate.

Supporting young adults with hemiplegia: services and costs.

This paper lays out the service and cost consequences of supporting a nationally representative sample of young adults with hemiplegic cerebral palsy. The total costs burden and the additional costs that accrue to the public and independent sector due to their disabilities are calculated. Most of the young adults live at home. Many lead "ordinary" lives and attend further or higher education establishments or go to work. A small number of study members, however, make intensive use of expensive, often segregated facilities such as residential homes or schools and make considerable use of other support services. In total, this group of 81 people cost just over 1 million pounds to support during the year prior to interview, 43% of which was related to their impairments. When the sample is divided into two groups, people with a combination of associated conditions are found to have hemiplegia-associated costs almost 50 times greater than those with simple hemiplegia.

Towards a cognitive niche: divergent foraging strategies resulting from limited cognitive ability of foraging herbivores in a spatially complex environment.

A model was developed to explain one mechanism whereby differential optimal foraging strategies can occur between species as a result of selection for competition avoidance. This is the primary requirement for niche differentiation to evolve without a difference in the underlying foraging ability or morphology. The model used an individual-based patch choice mechanism, whereby herbivores move from patch to patch seeking food with the highest nutrient intake characteristics. The choice of patch was governed by a parameter, mu, which determined to what extent information in the landscape at different distances from the herbivore was used by it to make foraging decisions. A genetic algorithm was used to optimise the value, mu, in a complex landscape. The value of mu quickly converged to a single value with stabilising selection occurring when there was only a single species foraging. When there was a competing species with a fixed value of mu, the value of mu evolved to be above or below the mean for the single species mean depending on whether the value of mu for the competitor was below, or above the single-species mean, respectively. This was indicative of niche segregation. However mu tended to vary unstably over time when allowed to vary simultaneously in both species, although there was evidence for interaction between the two values. These results indicate that there can be a competitive advantage in choosing a cognitive strategy that is complementary to that used by other species.

The European Socio-Demographic Schedule (ESDS): rationale, principles and development.

OBJECTIVE: To design an internationally valid and practical instrument on which data can be recorded for small areas that describes the sociodemographic characteristics known to be associated with psychiatric morbidity and service use. METHOD: (1) Identification of a set of sociodemographic characteristics which, on the basis of currently available evidence, would be expected to influence needs for and provision of mental health care in different countries. (2) Selection of a subset of these for inclusion in the schedule based on likely degree of cross-cultural validity and on the types and formats of the data routinely available in each country. (3) Revision of the schedule following a pilot by EPCAT members. RESULTS: The European Socio-Demographic Schedule (ESDS) was successfully employed to collect sociodemographic data in seven catchment areas. Differences were found between the areas in terms of availability of data as well as in the resulting profiles. CONCLUSION: The ESDS has been shown to be applicable in a number of European countries.

Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre.

OBJECTIVE: To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy. DESIGN: Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations. SETTING: Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996. PATIENTS AND PARTICIPANTS: 118 children with positive HIV antibody status. MAIN OUTCOME MEASURES AND RESULTS: Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was 18,600 Pounds per symptomatic non-AIDS patient per year and 46,600 Pounds per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to 8300 Pounds and 4800 Pounds per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to 152,400 Pounds (44,300 Pounds to 266,800 Pounds) compared with discounted lifetime costs of 122,700 Pounds (42,000 Pounds to 182,200 Pounds); nondiscounted lifetime costs for community care amounted to 24,300 Pounds (7900 Pounds to 41,600 Pounds) compared with discounted lifetime costs of 21,000 Pounds (6800 Pounds to 32,000 Pounds). CONCLUSIONS: The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospital and community-based services.

Mental health care in Italy: organisational structure, routine clinical activity and costs of a community psychiatric service in Lombardy region.

The Magenta Community Mental Health Centre (CMHC) is the public agency responsible for providing adult psychiatric care to about 85,000 adult residents. In 1995, it had 1,145 clients and incurred costs of Euro 1.9 millions. Average cost per patient and per adult resident were Euro 1,661 and Euro 22.2, respectively. These values mask large variation across diagnosis: while patients with schizophrenia and related disorders had an average cost of Euro 3,771, those with neurotic and related disorders had an average cost of Euro 439. Patients with schizophrenia and related disorders (28% of the patients) absorbed about 60% of total costs and made extensive use of several types of services (hospital, outpatient, domiciliary, social and rehabilitative care). Since integrating different types of services is the key element of Italian psychiatric care, the new fee-for-service system adopted by the NHS to fund providers does not appear appropriate, particularly for schizophrenic patients.

A randomised controlled trial to evaluate the effectiveness and cost-effectiveness of counselling patients with chronic depression.

OBJECTIVES: To examine the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression or combined depression and anxiety, compared with general practitioner (GP) care alone. DESIGN: A randomised controlled trial and economic evaluation with an initial assessment at randomisation and follow-ups at 6 and 12 months. SETTING: Nine general practices that were well-established participants of the Derbyshire counselling in general practice scheme, and already had a counsellor in the practice team. SUBJECTS: Patients were screened at GP practices, and asked to participate if they scored >/= 14 on the Beck Depression Inventory (BDI), had suffered depression or depression/anxiety for 6 months or more, were aged 18-70 and had no history of drug or alcohol abuse, psychoses or suicidal tendencies. INTERVENTIONS: The experimental group received usual GP treatment and were also referred to an experienced, well-qualified counsellor attached to their general practice. Of the eight counsellors, two practiced cognitive behavioural therapy (CBT) and six had a psychodynamic approach. The controls were referred back to their GP for routine treatment. There were no restrictions regarding the treatment that could be used, except that GPs could not refer controls to practice counsellors. OUTCOME MEASURES: The main outcome measure was the BDI. Others included the Brief Symptom Inventory, the Inventory of Interpersonal Problems and the Social Adjustment Scale. All tests were given at initial, 6- and 12-month assessments. Comprehensive costs were also estimated, and combined with changes in outcomes to examine between-group differences and whether counselling was more cost-effective than standard GP care. RESULTS: The trial recruited 181 patients. There was an overall significant improvement in the actual scores over time but no difference between groups or between CBT and psychodynamic counselling approaches at either 6 or 12 months. However, fewer experimental group patients were still 'cases' on the BDI than controls. This difference was statistically significant at 12 months and neared significance at 6 months (using logistic regression with the initial score as a covariate). In addition, most patients were very positive about the counselling and considered it helpful. Visual inspection of the outcomes suggested that more patients with mild or moderate depression at study entry had improved and ceased to be cases, and that more of these patients had become 'non-cases' in the experimental than the control group. However, a multiple regression analysis indicated no significant interactions between group and initial severity of depression. This could be partly due to there being no difference in outcome between the experimental and control group patients who were initially severely depressed and few of these patients ceasing to be cases at follow-up. There were no significant differences in the mean total costs, aggregate costs of services, or any of the service-group costs, except for primary care, between the experimental and control groups over time. The cost-burden to GP practices was significantly higher in the experimental than the control group at 6 months. CONCLUSIONS: Although patients were generally appreciative of the counselling received, there was only limited evidence of improved outcomes in those referred to counselling. Stricter referral criteria to exclude the severely depressed may have yielded more conclusive results. It is also difficult to estimate the effect of recruitment by screening rather than GP referral, which may limit the applicability of the results to routine clinical practice, and may have interfered with the normal working alliance established between the GP, patient and counsellor. A patient preference trial may, therefore, have been more appropriate. The results indicated that there were similar improvements for both CBT and psychodynamic counselling, but a

What is the cost of getting the price wrong?

BACKGROUND: The objective of this study was to compare differences in cost estimates for paediatric HIV hospital service provision based on hospital prices with cost estimates obtained through a research-based service-specific costing exercise. METHODS: Activity data on the use of hospital services of children by stage of HIV infection were collected from case-notes for 118 HIV antibody positive children, managed at St Mary's Hospital NHS Trust, London, 1 January 1986-31 December 1994. Hospital unit prices were obtained from the Hospital Trust Finance Department; unit cost estimates were obtained from relevant hospital departments through a research-based service-specific costing exercise. Financial data related to the 1993-1994 financial year, and were indexed to 1995-1996 prices. The main outcome measures were cost estimates per patient-year by stage of HIV infection. Three cost scenarios were calculated: first by linking activity data with hospital prices (Trust Prices); second by linking activity data with routinely available hospital prices plus units costs from the costing exercise where no relevant hospital prices existed (Supplemented Trust Prices); third, by linking activity data exclusively with unit costs from the hospital-specific costing exercise (Unit Costs). RESULTS: There were substantial differences between unit cost estimates per patient-year based on Trust Prices and Supplemented Trust Prices compared with those based on Unit Costs. Differences increased with more intense use of services. The deficit based on Trust Prices compared with Unit Costs ranged from Pound Sterling 432 per patient-year for HIV negative children, Pound Sterling 574 for asymptomatic HIV-infected children, Pound Sterling 1288 for indeterminate children, Pound Sterling 1814 for children with symptomatic non-AIDS to Pound Sterling 7418 per patient-year for children with AIDS. CONCLUSIONS: In this hospital, reliance on generic hospital prices to derive cost estimates for paediatric HIV services produced considerable underestimates of the cost of service provision compared with data derived through the costing exercise. If this occurs across all or most areas of service provision, this can lead to substantial financial deficits, which in turn may mean that the needs of specific client populations may not be met.

Shipboard impact of a probable Norwalk virus outbreak from coastal Japan.

Norwalk virus has been implicated in shipboard diarrheal disease outbreaks throughout Asia. A large outbreak of suspected Norwalk virus was investigated on a U.S. Naval aircraft carrier following the clinical recognition of 450 cases of gastroenteritis over a 2-week period (September 14-28, 1997) during coastal exercises. A random sampling of 44 cases from 450 personnel who sought medical attention was compared with 19 controls. Junior enlisted sailors and marines comprised 97% of all cases. There was no evidence of shipboard geographic clustering of cases. Furthermore, no single food type was associated with illness on the basis of comparative analysis (cases versus controls). Principal case signs and symptoms reported included watery stools (89%), nausea (82%), and vomiting (77%). Anecdotal reports indicated > 50% of the cases received rehydration therapy. An absence of fever was also noted in 32% of the cases and only 5% had blood in their stools. The mean duration of illness was 37 hr, with a range of 3-96 hr. Laboratory findings based on reverse transcription-polymerase chain reaction and Southern hybridization methods showed that 21 (72%) of 29 patients had evidence of the UK2 prototype of the Norwalk virus. A cross-sectional study of 131 crew members from the ships population (n = 4,200) showed an attack rate of 44%. Attack rate is a variant of an incident rate applied to a narrowly defined population observed for a limited period of time, such as during an outbreak. The numerator is people who get sick and the denominator is people (population) at risk. An extrapolation of these findings suggests as many as 1,806 sailors may have been affected during the outbreak, of which only 26% (of the 57 outbreak related cases) where identified from sick call records. There was no difference in the mean ages between outbreak and non-outbreak affected crewmen, or geographic clustering based on berthing or work spaces. Outbreak-related cases reported signs and symptoms of watery-stools (79%), nausea (65%), and vomiting (47%). The mean duration of illness was 28 hr, ranging from 2 to 96 hr. Thirty-one percent of outbreak affected cases reported a sick call visit. Loss of work was reported by 39% of the outbreak affected population. This report documents the epidemic potential of Norwalk virus and the associated impact on fleet operational readiness. Additionally, that this outbreak occurred against a background of 3 other consecutive gastroenteritis outbreaks onboard the same ship (March 1997, February/March 1998, and June 1998), all sharing the same clinical and epidemiologic profiles, suggests possible shipboard persistence of Norwalk virus over time, despite periodic ship-wide disinfection efforts.