Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective.

BACKGROUND: Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status. AIMS: The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada. METHODS: A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars. RESULTS: Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000. CONCLUSIONS: In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

Economic recession and mental health: an overview.

Effects of the current global economic downturn on population mental health will emerge in the years ahead. Judging from earlier experience of financial crises in various parts of the world, stresses associated with rising unemployment, poverty and social insecurity will lead to upward trends in many national suicide rates, as well as to less readily charted increase in the prevalence of psychiatric illness, alcohol-related disorders and illicit drug use. At the same time, mental health services are being cut back as part of government austerity programs. Budget cuts will thus affect psychiatric services adversely just when economic stressors are raising the levels of need and demand in affected populations. Proactive fiscal and social policies could, however, help to mitigate the health consequences of recession. Evidence- based preventive measures include active labor market and family support programs, regulation of alcohol prices and availability, community care for known high-risk groups, and debt relief projects. Economic mental health care could best be achieved, not by decimating services but by planning and deploying these to meet the needs of defined area populations.

British psychiatry and its discontents.

Psychiatry in the UK is currently faced with serious difficulties arising from failure in recruiting British doctors and a high rate of early retirement from the specialty. To diagnose the underlying causes, account must be taken of government policies affecting the NHS in general and mental health services in particular. The latter include an excessive run-down of acute hospital beds, as well as projects aimed at changing the clinical role of psychiatrists and promoting mass treatment of milder mental disorders by non-medical personnel. Psychiatrists have reacted to these developments with anger and dismay, but have as yet reached no consensus with regard to either causal factors or appropriate response. Their uncertainty reflects the need for a firmer grasp of the historical background. Modern British psychiatry was effectively created and moulded as an integral part of the NHS. It flourished as long as the public service framework remained intact, but has suffered a decline since the whole structure began to buckle under the pressure of sustained political assaults. A clearer understanding of this vital connection would help to raise psychiatrists' morale and encourage them to establish common ground with medical colleagues and other healthcare professionals.

Strange bedfellows: economics, happiness and mental disorder.

AIM: The high economic and social costs associated with the 'common mental disorders', and the need to scale up appropriate care services, are now widely recognized, but responses vary from country to country. In Britain, a current government initiative to promote psychological therapy is driven both by economic pressures and by research on the factors of happiness, or life-satisfaction. This article provides a short critical review of the project. METHOD: A health policy analysis, with regard to problem definition; objectives; sources of information; criteria for evaluation; impact on existing services, and comparison with alternative strategies. RESULTS: The new programme, Improving Access to Psychological Therapies (IAPT), aims to expand treatment services by training 3,600 'psychological therapists' in cognitive behavioural therapy (CBT), which they will then apply in the wider community. This service, with an initial budget of 173 million pounds sterling, will provide treatment for depression and chronic anxiety from local centres across the country. The programme is intended to pay for itself by reducing incapacity costs. Closer examination, however, raises questions concerning the project's theoretical basis, logistics and research methodology, and casts doubt on its advantages over alternative approaches. CONCLUSIONS: The IAPT project is ill-designed to achieve its objectives and unsuitable as a model for treatment and care of the common mental disorders in other countries. An alternative strategy, based on closer integration of community mental health and primary health care, should be tested and on previous experience seems likely to prove more cost-effective.

Exploring the nurse endoscopist role: a qualitative approach.

BACKGROUND: Previously, gastrointestinal endoscopy was undertaken only by medical staff. The nurse endoscopist role has recently been developed and is now in great demand. Barriers and facilitators are identified in similar nursing roles, though little research has been undertaken on the nurse endoscopist role. AIM: To examine perceptions of UK nurse endoscopists regarding their experience of the role. This qualitative study involved semi-structured interviews with eight UK nurse endoscopists. Data gained were analyzed qualitatively. The following categories emerged: role structure, collaboration, experience, and education and training. RESULTS: The 'role structure' category showed that patient services were better where the nurse endoscopist role encompassed a more holistic approach. In the 'collaboration' category, the importance of relations with medical, nursing and management colleagues was observed. It was found that nurse endoscopists may be providing an inferior service due to being given lower priority than medical endoscopists. The 'experience' category showed nurse endoscopists valued their nursing experience, while specific endoscopy nursing experience prior to becoming an endoscopist was also useful. The 'education' category showed that degree-level education and training were important when accessed, in addition to prescribing courses. CONCLUSION: Nurses undertaking endoscopy have potentially satisfying roles, which allow them to perform effectively. The roles should be planned adequately and practitioners should receive appropriate degree-level education. Furthermore, patients should receive equitable treatment regardless of which profession undertakes the endoscopy.

Development and initial validation of a family appraisal of caregiving questionnaire for palliative care.

This article describes the derivation and initial psychometric validation of a multi-dimensional Family Appraisal of Caregiving Questionnaire for Palliative Care (FACQ-PC). The 25-item measure consists of four theoretically derived subscales: (i) caregiver strain, (ii) positive caregiving appraisals, (iii) caregiver distress, and (iv) family well-being. Based on a sample of 160 family caregivers of a relative with cancer receiving palliative care, reliability analyses demonstrated the subscale scores to be internally consistent and factor analysis revealed evidence of factorial validity. Correlations of the four subscales with measures of family functioning, positive and negative affect, and subjective burden provided evidence of convergent and discriminant validity. The FACQ-PC provides a measure of the family's appraisal of caregiving that can be used in clinical assessment, and has potential utility for evaluating the effectiveness of palliative care interventions.

Schizophrenia, social class and immigrant status: the epidemiological evidence.

BACKGROUND: By the mid-1960s, the importance of socio-economic status for schizophrenia had been demonstrated in terms of differences between social-class groups in prevalence and incidence rates, illness course and outcome, and treatment experience. In the causation-selection debate, however, opinion had swung in favour of the selection hypothesis. AIMS: To reassess evidence on the social-class distribution of schizophrenia in Britain, and to compare this body of research with population-based studies of schizophrenia risk in socially disadvantaged ethnic minorities. METHOD: Systematic review of medical and psychological data-bases. RESULTS: Epidemiological research, while confirming the importance of premorbid social decline, has also provided support for the environmental 'breeder' hypothesis. High psychosis rates have been confirmed in ethnic minorities; in particular among Afro-Caribbean and other Black immigrants whose low social status cannot be accounted for by selective downward social drift or segregation. CONCLUSIONS: There are striking parallels, both in the epidemiology of schizophrenia and in social characteristics, between the lower-class indigenous groups highlighted by earlier psychiatric surveys and African-Caribbean populations in Britain's inner cities today. These similarities underline the need for a broader perspective in the search for environmental risk factors.

Ethnicity, gender, and socioeconomic status as risk factors for esophagitis and Barrett's esophagus.

Barrett's esophagus is thought to be a disease occurring predominantly in White Caucasian males of higher socioeconomic status. There are no published studies simultaneously examining risk of Barrett's esophagus according to ethnicity, gender, and socioeconomic status within a single data set. The authors conducted a retrospective case-control analysis within a cross-sectional study to determine risk of Barrett's esophagus in relation to sociodemographic variables in a large United Kingdom population. All patients undergoing upper gastrointestinal endoscopy at two clinical centers between January 2000 and January 2003 were evaluated. Data on ethnicity, age, gender, socioeconomic status, and the presence of Barrett's esophagus and esophagitis at endoscopy were collected. A total of 20,310 patients were analyzed. Barrett's esophagus was more common in White Caucasians (401/14,095 (2.8%)) than in South Asians (16/5,190 (0.3%)) (adjusted odds ratio (OR)=6.03, 95% confidence interval (CI): 3.56, 10.22), as was esophagitis (2,500/14,095 (17.7%) vs. 557/5,190 (10.7%); adjusted OR=1.76, 95% CI: 1.57, 1.97). Patients with Barrett's esophagus were also more likely to be male (adjusted OR=2.70, 95% CI: 2.18, 3.35) and of higher socioeconomic status (adjusted OR=1.58, 95% CI: 1.16, 2.15 (top tertile vs. bottom tertile)). White Caucasian ethnicity, male gender, and higher socioeconomic status are independent risk factors for Barrett's esophagus.

Dose-dependent misrejoining of radiation-induced DNA double-strand breaks in human fibroblasts: experimental and theoretical study for high- and low-LET radiation.

Misrejoining of DNA double-strand breaks (DSBs) was measured in human primary fibroblasts after exposure to X rays and high-LET particles (helium, nitrogen and iron) in the dose range 10-80 Gy. To measure joining of wrong DNA ends, the integrity of a 3.2-Mbp restriction fragment was analyzed directly after exposure and after 16 h of repair incubation. It was found that the misrejoining frequency for X rays was nonlinearly related to dose, with less probability of misrejoining at low doses than at high doses. The dose dependence for the high-LET particles, on the other hand, was closer to being linear, with misrejoining frequencies higher than for X rays, particularly at the lower doses. These experimental results were simulated with a Monte Carlo approach that includes a cell nucleus model with all 46 chromosomes present, combined with realistic track structure simulations to calculate the geometrical positions of all DSBs induced for each dose. The model assumes that the main determinant for misrejoining probability is the distance between two simultaneously present DSBs. With a Gaussian interaction probability function with distance, it was found that the data for both low- and high-LET radiation could be fitted with an interaction distance (sigma of the Gaussian curve) of 0.25 microm. This is half the distance previously found to best fit chromosomal aberration data in human lymphocytes using the same methods (Holley et al., Radiat. Res. 158, 568-580, 2002). The discrepancy may indicate inadequacies in the chromosome model, for example insufficient chromosomal overlap, but may also be partly due to differences between fibroblasts and lymphocytes.

Evidence-based mental health policy: a critical appraisal.

BACKGROUND: Arguments for and against evidence-based psychiatry have mostly centred on its value for clinical practice and teaching. Now, however, use of the same paradigm in evaluating health care has generated new problems. AIMS: To outline the development of evidence-based health care; to summarise the main critiques of this approach; to review the evidence now being employed to evaluate mental health care; and to consider how the evidence base might be improved. METHOD: The following sources were monitored: publications on evidence-based psychiatry and health care since 1990; reports of randomised trials and meta-analytic reviews to the end of 2002; and official British publications on mental health policy. RESULTS: Although evidence-based health care is now being promulgated as a rational basis for mental health planning in Britain, its contributions to service evaluation have been distinctly modest. Only 10% of clinical trials and meta-analyses have been focused on effectiveness of services, and many reviews proved inconclusive. CONCLUSIONS: The current evidence-based approach is overly reliant on meta-analytic reviews, and is more applicable to specific treatments than to the care agencies that control their delivery. A much broader evidence base is called for, extending to studies in primary health care and the evaluation of preventive techniques.