Better care for less money: cost-effectiveness of integrated care in multi-episode patients with severe psychosis.

OBJECTIVE: To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis. METHOD: Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up. RESULTS: At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (€-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (€+1417). Both resulted in lower total costs in IC-TACT (mean difference = €-13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%. CONCLUSION: IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 1: Häufigkeit, Störungspersistenz, Belastungsfaktoren, Service-Inanspruchnahme und Behandlungsverzögerung mit Konsequenzen.

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

The dilemma of insight into illness in schizophrenia: self- and expert-rated insight and quality of life.

INTRODUCTION: A major subgroup of patients with acute schizophrenia lacks awareness of having a mental disorder. The aim of this study was to investigate the association of self- and expert-rated insight into illness with subjective quality of life (QOL). It was hypothesised that patients with greater self- and expert-rated insight into illness report lower QOL compared to patients with poor insight. METHOD: For the present study, patients with schizophrenia or schizoaffective disorders were investigated during in-patient treatment. Insight into illness was measured by the scale to assess unawareness of a mental disorder (SUMD), the insight scale and the PANSS. QOL was assessed with the modular system of quality of life (MSQoL). Results Fifty-nine patients entered the study. Self- and expert-rated illness insight were associated with poor QOL. Patients with good insight into illness reported significantly lower physical health (p < 0.05), vitality (p < 0.01), psychosocial (p < 0.01), affective (p < 0.01) and general QOL (p < 0.001) compared to patients with poor insight. Good insight was significantly associated with other parameters of clinical and social functioning and depressive symptoms. DISCUSSION: The results indicate that patients with acute schizophrenia and greater insight realise their restrictions more clearly, which contribute to poor QOL, but were stronger integrated in social networks. The inclusion of modules focussing on QOL related aspects of treatment from the beginning as well as a greater awareness of the physician for these questions and a strengthening of the therapeutic alliance might help improving insight without the risk of deteriorating mood and QOL.

[Treatment oriented to subjective well- being rather than symptom amelioration "at all costs"--paradigm change in treatment with antipsychotics]. / Befindlichkeitsorientierte Therapie mit Antipsychotika. Auch die Gefühle Ihrer Patienten zählen.

Modern antipsychotics differ from the classical drugs mainly in their improved efficacy in combating affective, negative and cognitive symptoms and by a modified side effect profile. The variability range of such substances enable a more differentiated approach to treatment to be adopted. Patients treated with typical antipsychotics report a more pronounced improvement in subjective well-being. In view of the increasing numbers of atypical antipsychotics, the involvement of the patients in the selection of the most appropriate drug is a must. Apart from symptom amelioration - the formerly predominant goal of treatment - greater emphasis is now placed on the well-being of the individual patient on antipsychotic therapy. With this approach, the physician-patient relationship, compliance and the long-term prognosis can all be appreciably improved.

Reproductive issues for men with cancer: technology and nursing management.

PURPOSE/OBJECTIVES: To review the current medical technologies available to protect the reproductive potential of adult males undergoing sterilizing cancer treatments; to describe the attributes and limitations of these technologies and how oncology nurses can access them for the patient; and to discuss psychosocial elements, including the legal considerations of oncology nurses who counsel patients. DATA SOURCES: Quantitative data from personal clinical records; personal clinical experience; published articles, abstracts, and books identified by bibliographic data base searches; and consultation with lawyers. DATA SYNTHESIS: Cancer treatment can have severe and adverse long-term iatrogenic effects on male fertility. Medical technologies that protect male reproduction potential from sterilizing procedures have progressed from unreliable to clinically practical over a period of 20 years. The present clinical means for preserving the potential reproductive capacity of men at risk is cryopreservation of sperm before treatment begins, followed by assisted reproductive technology when pregnancy is desired. Medical, legal, and religious issues relevant to counseling are involved. CONCLUSIONS: Current reproductive technology provides realistic hope for future procreation by men facing sterilizing cancer treatment. IMPLICATIONS FOR NURSING PRACTICE: Nursing intervention primarily involves providing patient counseling and arranging patient access to cryopreservation facilities. Oncology nurses can assist men making these types of reproductive decisions by assessing their medical and psychological need for information and by counseling them in regard to human sexuality, the fertility risk of oncologic therapy, the availability of reproductive interventions, and the social ramifications of using stored semen.

Functional preservation of the mammalian kidney. VI. Viability assessment of rabbit kidneys perfused at 25 degrees C with dimethyl sulfoxide in RPS-2.

The study utilizes an ex vivo perfusion model to evaluate the effects of warm perfusion (25 degrees C) with two K+-rich vehicle solutions (RPS-2 and solution A) on whole rabbit kidneys. The suitability of the solutions as vehicles for introducing cryoprotectant concentrations (2.8 and 3.5 M) of dimethyl sulfoxide (Me2SO) and the effects of the addition of albumin to RPS-2 are also tested. Albumin (5 g/dl) does not appreciably improve the renal perfusion dynamics of RPS-2. Results indicate that both RPS-2 and solution A serve as effective vehicles for the introduction of 2.8 M Me2SO, and the continued investigation of the RPS-2/Me2SO protocol is advocated.

Factors to consider in the assessment of viability of cryopreserved islets of Langerhans.

With the development of techniques for the isolation and transplantation of pancreatic islets of Langerhans, research has been directed toward low-temperature storage of islets as a means of preservation. For successful islet cryopreservation several factors must be considered. In these studies we have investigated the effects of the cryoprotectant dimethyl sulfoxide (Me2SO) on islet function in the absence of freezing. We have found that Me2SO pretreatment can inhibit subsequent glucose-induced insulin release, but this effect can be minimized by hypothermic exposure to the cryoprotectant using a stepwise addition and dilution protocol for treatment. By studying islet function after freezing and thawing, we have found also that a slow cooling rate (0.3 degrees C/min) results in optimal survival and that islet function can be significantly improved by increasing the duration of post-thaw culture. The results of these studies address only a few of the many questions that need to be answered before clinical application of cryopreserved islet transplantation occurs.