Prison prescribing practice: practitioners' perspectives on why prison is different.

The current prison population in England and Wales has multiple, complex healthcare needs, presenting unique challenges to those caring for prisoners. Prison numbers have increased dramatically in the last 10 years. There are now approximately 84,000 prisoners in England and Wales and 120,000 new episodes of imprisonment each year . The authors all contribute to prison healthcare. Below, we discuss a key issue arising from first-hand experience of prisoners' health and social care needs, the prescription of psycho-active drugs by primary and secondary care practitioners. This is a core medical task, but beset with difficulties. These difficulties are not necessarily encountered in other areas of prison healthcare. However, they do illustrate how providing healthcare to prisoners is complex, often lacking a research base and can have pitfalls that are not obvious to the outsider.

Suicide and attempted suicide among people of Caribbean origin with psychosis living in the UK.

BACKGROUND: A report from a 1980s cohort claimed that suicidal behaviour was four times less common in UK-resident people of Caribbean origin with psychosis than in British Whites. Since then, evidence has accumulated that the rate of suicide and suicidal ideation has been increasing. Aims To compare rates of suicidal behaviour in people of Caribbean and British White origin in a large multi-centre sample of patients with psychosis. METHOD: A secondary analysis of 708 patients with psychosis followed up for 2 years. Outcome measures of reported suicide and attempted suicide were adjusted for socio-economic and clinical differences between groups at baseline. RESULTS: People of Caribbean origin had a lower risk of suicidal behaviour than British Whites (odds ratio adjusted for age and gender 0.49, 95% CI 0.26-0.92). There was a strong negative interaction between ethnic group and age: suicidal acts were four times less likely in people of Caribbean origin aged over 35 years compared with British Whites, but there was no large or significant difference in those under 35. CONCLUSIONS: The previously reported lower relative risk of suicidal behaviour in people of Caribbean origin with psychosis is restricted to those over 35 years, suggesting that the protective effect of Caribbean origin is disappearing in younger generations.

Comparison of the outcome and treatment of psychosis in people of Caribbean origin living in the UK and British Whites. Report from the UK700 trial.

BACKGROUND: The comparative outcome of psychosis in British Whites and UK African-Caribbeans is unclear. Some report that African-Caribbeans have worse outcome, whereas others claim better symptomatic outcome and a more benign course. AIMS: To compare the course, outcome and treatment of psychosis in African-Caribbeans and British Whites in a large multi-centre sample. METHOD: A secondary analysis of 708 patients with research diagnostic criteria-defined psychosis from a 2-year, randomised controlled trial of case management. Outcome measures (hospitalisation, illness course, self-harm, social disability and treatment received) were adjusted for socio-economic and clinical differences between groups at baseline using regression analysis. RESULTS: African-Caribbeans were less likely to have a continuous illness and to receive treatment with antidepressant or psychotherapy. CONCLUSIONS: The outcome of psychosis is complex but differs between UK African-Caribbeans and British Whites. This may reflect risk factors that increase the rate of psychosis in UK African-Caribbeans. Treatment differences require further investigation.

Diagnostic value of the DSM and ICD categories of psychosis: an evidence-based approach. UK700 Group.

BACKGROUND: It is generally assumed that the distinction between affective and non-affective psychosis occasioned by modern diagnostic criteria provides a useful symptomatic contrast. METHOD: In a sample of 708 patients with chronic psychosis, the distinction of lifetime DSM-III-R and ICD-10 diagnoses of affective versus non-affective psychosis was used as a diagnostic test to detect lifetime presence of depressive, manic, positive, negative and disorganisation symptoms. RESULTS: A manic or depressive affective diagnosis was a perfect test to diagnose the presence of manic and depressive symptoms, as evidenced by very high diagnostic likelihood ratios. However, this test result was based solely on the inclusion criterion that patients with affective psychosis must have affective symptoms (guaranteeing high specificity and high likelihood ratios), and ignored the fact that patients with non-affective psychosis also had high affective symptom scores (low sensitivity). Furthermore, a non-affective psychotic diagnosis was a very poor test to diagnose correctly the presence of positive, negative and disorganisation symptoms in comparison with an affective psychotic diagnosis. In general, the DSM-III-R categories performed somewhat better as a diagnostic test than those of ICD-10. CONCLUSION: The evidence for true diagnostic value of the distinction between affective and non-affective psychotic diagnoses is weak. Rather, the distinction appears to obscure natural overlap between the symptom dimensions of the different diagnostic categories.

Changes in negative symptoms and the risk of tardive dyskinesia: a longitudinal study. UK700 Group.

OBJECTIVE: To examine whether the development of tardive dyskinesia (TD) is accompanied by a parallel process of worsening negative symptoms in a longitudinal study. METHOD: A sample of 708 psychotic patients were followed over a period of 2 years, using the Abnormal Involuntary Movement Scale and the Scale for the Assessment of Negative Symptoms (SANS). RESULTS: Of 361 individuals with no prior evidence of dyskinesia, 46 (13%) developed TD by year 2. Independent of the effects of male sex (odds ratio (OR)=2.18, 95% confidence interval: 1.00-4.74), age (OR per quartile group = 1.39, 95% CI: 1.01-1.90), duration of exposure to antipsychotic medication (OR = 2.35 per 8 months, 95% CI: 1.17-4.72) and average SANS score (OR per quartile group = 1.38, 95% CI: 0.99-1.93), worsening of negative symptoms over the 2 previous years was associated with TD onset (OR per quartile group = 1.46, 95% CI: 1.07-2.00). CONCLUSION: The development of TD is linked, independent of the effect of antipsychotics and older age, to an illness-related pathological process, characterized by worsening negative symptoms.

Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial.

One hundred fifty-five (77%) of 201 participants recruited in a trial of intensive vs standard case management of patients with recurrent psychotic illness had their personality status measured before treatment and were followed up for two years. The primary outcome was the total number of days spent in psychiatric hospitalisation in the two years following randomisation. Thirty-three (21%) of the patients had a personality disorder and their duration of hospital stay (105 days) was greater than in those without personality disorder (56 days). There was weak evidence that intensive case management more effective in reducing the duration of care in those with personality disorder than in those without personality disorder.

Problems in developing an instrument for the rapid assessment of personality status.

PURPOSE: To assess the validity of a quick assessment instrument (10 minutes) for assessing personality status, the Rapid Personality Assessment Schedule (PAS-R). SUBJECTS AND METHODS: The PAS-R was evaluated in psychotic patients recruited in one of the centres involved in a multicentre randomised controlled trial of intensive vs standard case management (the UK700 case management trial). Patients were assessed using both a full version of the PAS (PAS-I - ICD version) and the PAS-R. The weighted kappa statistic was used to gauge the (criterion-related) validity of the PAS-R using the PAS-I as the gold standard. Both measure code personality status using a four-point rating of severity in addition to recording individual categories of personality disorder. RESULTS: One hundred fifty-five (77%) of 201 patients recruited were assessed with both instruments. The weighted kappa statistic was 0.31, suggesting only moderate agreement between the PAS-I and PAS-R instruments under the four-point rating format, and 0.39 for the dichotomous personality disorder/no disorder separation. The sensitivity (64%) and specificity (82%) of the PAS-R in predicting PAS-I personality disorder were as satisfactory as for other screening instruments but still somewhat disappointing, and the PAS-R had an overall diagnostic accuracy of 78%. CONCLUSION: The PAS-R is a quick and rough method of detecting personality abnormality but is not a substitute for a fuller assessment.

The effect of critical care hospitalization on family members: stress and responses.

Family members of intensive care patients may experience stressors that threaten both personal health and family integrity. This study found that family members endure multiple concurrent stressors and exhibit numerous behavioral responses, including changes in eating, sleeping, activity, and family roles and responsibilities. Nurses can promote family integrity with interventions that address these behavioral changes and promote normal behavior patterns.

To what extent does symptomatic improvement result in better outcome in psychotic illness? UK700 Group.

BACKGROUND: The effectiveness of therapeutic interventions in psychosis is increasingly reported in terms of reductions in different symptom dimensions. It remains unclear, however, to what degree such symptomatic changes are accompanied by improvement in other measures such as service use, quality of life, and needs for care. METHODS: A sample of 708 patients with chronic psychotic illness was assessed on three occasions over 2 years (baseline, year 1 and year 2). A multilevel analysis was conducted to examine to what degree reduction in psychopathological scores derived from factor analysis of the Comprehensive Psychopathological Rating Scale (CPRS), was associated with improvement in service use, disability, subjective outcomes and measures of self-harm. RESULTS: Reduction in positive, negative, depressive and manic symptoms over the study period were all independently associated with lessening of social disability. Reduction in negative symptoms, and to a lesser extent in positive and manic symptoms, was associated with less time in hospital and more time living independently, whereas changes in positive and manic symptoms resulted in fewer admissions. Subjective outcomes such as improvement in quality of life, perceived needs for care and dissatisfaction with services showed the strongest associations with reduction in depressive symptoms. Reduction in positive symptoms was associated with decreased likelihood of parasuicide. Results did not differ according to diagnostic category. CONCLUSION: The findings suggest that changes in distinct psychopathological dimensions independently and differentially influence outcome. Therapeutic interventions aimed at reducing symptoms of more than one dimension are likely to have more widespread effects.

A comparison of the utility of dimensional and categorical representations of psychosis. UK700 Group.

BACKGROUND: The usefulness of any diagnostic scheme is directly related to its ability to provide clinically useful information on need for care. In this study, the clinical usefulness of dimensional and categorical representations of psychotic psychopathology were compared. METHOD: A total of 706 patients aged 16-65 years with chronic psychosis were recruited. Psychopathology was measured with the Comprehensive Psychopathological Rating Scale (CPRS). Lifetime RDC, DSM-III-R, and ICD-10 diagnoses and ratings of lifetime psychopathology were made using OPCRIT. Other clinical measures included: (i) need for care; (ii) quality of life; (iii) social disability; (iv) satisfaction with services; (v) abnormal movements; (vi) brief neuropsychological screen; and (vii) over the last 2 years--illness course, symptom severity, employment, medication use, self-harm, time in hospital and living independently. RESULTS: Principal component factor analysis of the 65 CPRS items on cross-sectional psychopathology yielded four dimensions of positive, negative, depressive and manic symptoms. Regression models comparing the relative contributions of dimensional and categorical representations of psychopathology with clinical measures consistently indicated strong and significant effects of psychopathological dimensions over and above any effect of their categorical counterparts, whereas the reverse did not hold. The effect of psychopathological dimensions was mostly cumulative: high ratings on more than one dimension increased the contribution to the clinical measures in a dose-response fashion. Similar results were obtained with psychopathological dimensions derived from lifetime psychopathology ratings using the OCCPI. CONCLUSIONS: A dimensional approach towards classification of psychotic illness offers important clinical advantages.

Tardive dyskinesia in psychosis: are women really more at risk? UK700 Group.

It is commonly held that women are more at risk of developing tardive dyskinesia (TD). However, recent evidence suggests that this may only be the case in samples of older patients, men being more at risk in the younger age groups. Abnormal movements were measured with the Abnormal Involuntary Movement Scale (AIMS) in a sample of 706 chronic psychotic patients aged not older than 65 years (median age 36 years). Female gender was associated with a lower risk of TD (OR, 0.5; 95% CI, 0.3-0.7). The effect of gender was independent of other risk factors such as older age, severity of negative symptoms and exposure to antipsychotic medication in the previous 2 years. There was no evidence that the effect of these risk factors differed between the sexes. In samples of relatively young patients with chronic psychotic illness, who typically represent the majority of patients in community programmes for the severely mentally ill, men are more at risk of TD than women.

Development of a social work case management guideline and model.

This article describes the process that a team of Department of Veterans Affairs social work service department heads went through as they developed national guidelines for social work case management. Many of the concepts and findings of this team apply to case managers in any profession.

A randomised controlled study of close monitoring of vulnerable psychiatric patients.

The care programme approach was introduced in mental health services in the UK in 1991. It was intended to improve the quality of care and prevent patients losing contact with care services and, by implication, to reduce psychiatric admissions. We did a study to find out if the approach worked. 400 patients from a London inner-city area who had been identified as psychiatrically vulnerable and included on a case register of patients with special needs were randomised into two groups of 200 each. One group received close supervision by nominated key-workers (as recommended in the care programme approach of the UK Department of Health), and the other received standard follow-up from psychiatric and social services. Outcome was recorded after eighteen months. Data on 393 patients was available for analysis. Of 197 patients allocated to standard care, 64 (32.5%) were lost to follow-up compared with 40 (20.4%) of 196 patients receiving close supervision (p = < 0.005). However, patients under close supervision had significantly more admissions (30% vs 18%, chi 2 = 7.61, p < 0.01) and spent 68% more days in hospital than the standard group. The findings of greater hospital-bed use, which differ from those of studies with community-based psychiatric teams, suggest that close supervision by a single key worker, as recommended in the care programme approach, will lead to greater success in maintaining contact with vulnerable patients, but is likely to lead to more psychiatric admissions.