Whose responsibility? Part 2 of 2: views of patients, families, and clinicians about responsibilities for addressing the needs of persons with mental health problems in Chennai, India and Montreal, Canada.

BACKGROUND: Individuals with mental health problems have many insufficiently met support needs. Across sociocultural contexts, various parties (e.g., governments, families, persons with mental health problems) assume responsibility for meeting these needs. However, key stakeholders' opinions of the relative responsibilities of these parties for meeting support needs remain largely unexplored. This is a critical knowledge gap, as these perceptions may influence policy and caregiving decisions. METHODS: Patients with first-episode psychosis (n = 250), their family members (n = 228), and clinicians (n = 50) at two early intervention services in Chennai, India and Montreal, Canada were asked how much responsibility they thought the government versus persons with mental health problems; the government versus families; and families versus persons with mental health problems should bear for meeting seven support needs of persons with mental health problems (e.g., housing; help covering costs of substance use treatment; etc.). Two-way analyses of variance were conducted to examine differences in ratings of responsibility between sites (Chennai, Montreal); raters (patients, families, clinicians); and support needs. RESULTS: Across sites and raters, governments were held most responsible for meeting each support need and all needs together. Montreal raters assigned more responsibility to the government than did Chennai raters. Compared to those in Montreal, Chennai raters assigned more responsibility to families versus persons with mental health problems, except for the costs of substance use treatment. Family raters across sites assigned more responsibility to governments than did patient raters, and more responsibility to families versus persons with mental health problems than did patient and clinician raters. At both sites, governments were assigned less responsibility for addressing housing- and school/work reintegration-related needs compared to other needs. In Chennai, the government was seen as most responsible for stigma reduction and least for covering substance use services. CONCLUSIONS: All stakeholders thought that governments should have substantial responsibility for meeting the needs of individuals with mental health problems, reinforcing calls for greater government investment in mental healthcare across contexts. The greater perceived responsibility of the government in Montreal and of families in Chennai may both reflect and influence differences in cultural norms and healthcare systems in India and Canada.

Whose responsibility? Part 1 of 2: A scale to assess how stakeholders apportion responsibilities for addressing the needs of persons with mental health problems.

BACKGROUND: Individuals with mental health problems have multiple, often inadequately met needs. Responsibility for meeting these needs frequently falls to patients, their families/caregivers, and governments. Little is known about stakeholders' views of who should be responsible for these needs and there are no measures to assess this construct. This study's objectives were to present the newly designed Whose Responsibility Scale (WRS), which assesses how stakeholders apportion responsibility to persons with mental health problems, their families, and the government for addressing various needs of persons with mental health problems, and to report its psychometric properties. METHODS: The 22-item WRS asks respondents to assign relative responsibility to the government versus persons with mental health problems, government versus families, and families versus persons with mental health problems for seven support needs. The items were modelled on a World Values Survey item comparing the government's and people's responsibility for ensuring that everyone is provided for. We administered English, Tamil, and French versions to 57 patients, 60 family members, and 27 clinicians at two early psychosis programs in Chennai, India, and Montreal, Canada, evaluating test-retest reliability, internal consistency, and ease of use. Internal consistency estimates were also calculated for confirmatory purposes with the larger samples from the main comparative study. RESULTS: Test-retest reliability (intra-class correlation coefficients) generally ranged from excellent to fair across stakeholders (patients, families, and clinicians), settings (Montreal and Chennai), and languages (English, French, and Tamil). In the standardization and larger confirmatory samples, internal consistency estimates (Cronbach's alphas) ranged from acceptable to excellent. The WRS scored average on ease of comprehension and completion. Scores were spread across the 1-10 range, suggesting that the scale captured variations in views on how responsibility for meeting needs should be distributed. On select items, scores at one end of the scale were never endorsed, but these reflected expected views about specific needs (e.g., Chennai patients never endorsed patients as being substantially more responsible for housing needs than families). CONCLUSIONS: The WRS is a promising measure for use across geo-cultural contexts to inform mental health policies, and to foster dialogue and accountability among stakeholders about roles and responsibilities. It can help researchers study stakeholders' views about responsibilities, and how these shape and are shaped by sociocultural contexts and mental healthcare systems.

Economic Evaluation of Extended Early Intervention Service vs Regular Care Following 2 Years of Early Intervention: Secondary Analysis of a Randomized Controlled Trial.

Cost-effectiveness studies of early intervention services (EIS) for psychosis have not included extension beyond the first 2 years. We sought to evaluate the cost-effectiveness of a 3-year extension of EIS compared to regular care (RC) from the public health care payer's perspective. Following 2 years of EIS in a university setting in Montreal, Canada, patients were randomized to a 3-year extension of EIS (n = 110) or RC (n = 110). Months of total symptom remission served as the main outcome measure. Resource use and cost data for publicly covered health care services were derived mostly from administrative systems. The incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were produced. Relative cost-effectiveness was estimated for those with duration of untreated psychosis (DUP) of 12 weeks or less vs longer. Extended early intervention had higher costs for psychiatrist and nonphysician interventions, but total costs were not significantly different. The ICER was $1627 per month in total remission. For the intervention to have an 80% chance of being cost-effective, the decision-maker needs to be willing to pay $5942 per month of total symptom remission. DUP ≤ 12 weeks was associated with a reduction in costs of $12 276 even if no value is placed on additional months in total remission. Extending EIS for psychosis for people, such as those included in this study, may be cost-effective if the decision-maker is willing to pay a high price for additional months of total symptom remission, though one commensurate with currently funded interventions. Cost-effectiveness was much greater for people with DUP ≤12 weeks.

Adequacy of Help Received by Individuals with Severe Mental Disorders After a Major Healthcare Reform in Quebec: Predictors and Changes at 5-Year Follow-Up.

This study assessed predictors and changes in adequacy of help received (AHR), as perceived by 204 individuals with severe mental disorders (SMDs) transferred from a mental health institution to the community following a key healthcare reform. Adjusted perceived AHR remained stable after 2 years (T1), but decreased at 5-year follow-up (T2). Predictors of higher adjusted perceived AHR are age, severity of needs, help received from services and relatives, and number of health professionals consulted. Community mental health services need to address the two major predictors of adjusted perceived AHR: severity of needs among individuals with SMDs and level of help from services.

Stability of leisure participation from school-age to adolescence in individuals with cerebral palsy.

With increasing age, youth with disabilities are at risk for decreased participation in leisure activities, a key component for physical and mental health. This prospective study describes changes in leisure participation and leisure preferences from school-age to adolescence in children with cerebral palsy (CP). Participants were recruited at school-age (6-12 years) for a study on participation and reassessed for a second study on adolescents (12-19 years) if >12 years. Thirty-eight children (24 males) with CP who could actively participate in the completion of the Children's Assessment of Participation and Enjoyment (CAPE) and the Preferences for Activities of Children (PAC) comprised the sample. Average time between assessments was 5.0 ± 1.3 years. Most children were ambulatory (32/38 Gross Motor Function Classification System I-II). In addition to the CAPE and PAC, children were evaluated using the Gross Motor Function Measure-66 and parents completed a socio-demographic questionnaire. Paired t-tests revealed a significant decline in leisure participation diversity and intensity (CAPE) for recreation (p<.0001), skill-based (p<.0001) and self-improvement (p<.05) activities, whereas social participation remained stable (p>.05). Diversity of active-physical activities increased modestly (p=.06) although intensity of participation in this activity domain decreased (p=.003). There was also a decline in enjoyment of leisure activities. Preferences for these leisure activities remained unchanged between school-age and adolescence, except for recreational activities. Gender, maternal education, family income and gross motor ability were not related to differences in CAPE/PAC scores with increasing age. Findings suggest that over time, children with CP's participation in leisure activities diminishes, which is of concern to their functioning and well-being. Parents may be more involved in early childhood in facilitating participation whereas in adolescence, youth may be faced with more environmental barriers and a greater awareness of challenges to participation. Adolescents demonstrated a persisting desire to do these activities, challenging rehabilitation specialists to prioritize strategies to promote greater participation as children transition to adolescence.

The Neighbourhood Built Environment and Trajectories of Depression Symptom Episodes in Adults: A Latent Class Growth Analysis.

AIM: To investigate the effect of the neighbourhood built environment on trajectories of depression symptom episodes in adults from the general Canadian population. RESEARCH DESIGN AND METHODS: We used 10 years of data collection (2000/01-2010/11) from the Canadian National Population Health Study (n = 7114). Episodes of depression symptoms were identified using the Composite International Diagnostic Interview Short-Form. We assessed the presence of local parks, healthy food stores, fast food restaurants, health services and cultural services using geospatial data. We used latent class growth modelling to identify different trajectories of depression symptom episodes in the sample and tested for the effect of neighbourhood variables on the trajectories over time. RESULTS: We uncovered three distinct trajectories of depression symptom episodes: low prevalence (76.2% of the sample), moderate prevalence (19.2%) and high prevalence of depression symptom episodes (2.8%). The presence of any neighbourhood service (healthy food store, fast-food restaurant, health service, except for cultural service) was significantly associated with a lower probability of a depression symptom episode for those following a trajectory of low prevalence of depression symptom episodes. The presence of a local park was also a significant protective factor in trajectory groups with both low and moderate prevalence of depression symptom episodes. Neighbourhood characteristics did not significantly affect the trajectory of high prevalence of depression symptom episodes. CONCLUSIONS: For individuals following a trajectory of low and moderate prevalence of depression symptom episodes, the neighbourhood built environment was associated with a shift in the trajectory of depression symptom episodes. Future intervention studies are recommended to make policy recommendations.

Demographic, lifestyle, and health characteristics of older adults with prediabetes in England.

OBJECTIVE: To describe the demographic, lifestyle, and health characteristics of older adults with prediabetes compared to those with normal glucose levels or diabetes. METHOD: Participants were from the English Longitudinal Study of Aging 2004-2005 (n=4168). Statistical analyses examined differences between people with prediabetes and 1) people with normal glucose levels and 2) people with diabetes. Design-based F-statistics and t-tests tested differences for each characteristic individually and multinomial logistic regression examined adjusted associations. Survey weighting and cluster information was used to generalize to the older English population. RESULTS: Compared to people with normal glucose levels, people with prediabetes were older (RR=1.05 95% CI 1.04-1.07), more likely to be employed (RR=1.27 95% CI 1.01-1.60), more likely to smoke (RR=2.21 95% CI 1.74-2.80), and had higher BMIs (RR=1.08 95% CI 1.06-1.10). Compared to people with diabetes, people with prediabetes were more likely to be women (RR=2.12 95% CI 1.57-2.86), more likely to be employed (RR=1.54 95% CI 1.02-2.33), had lower BMIs (RR=0.95 95% CI 0.93-0.98), were less likely to have a cardiovascular condition (RR=0.34 95% CI 0.24-0.47), and had higher self-rated health (χ(2)=26.08, p<0.001). CONCLUSION: Older adults with prediabetes have a unique set of characteristics that may inform prevention or intervention schemes.

Associations between diabetes, major depressive disorder and generalized anxiety disorder comorbidity, and disability: findings from the 2012 Canadian Community Health Survey--Mental Health (CCHS-MH).

OBJECTIVE: To examine the associations between diabetes, disability, and the likelihood of comorbid major depressive disorder (MDD) and generalized anxiety disorder (GAD). METHODS: Data were obtained from the 2012 Canadian Community Health Survey - Mental Health (N=17 623). Diabetes assessment consisted of a self-reported diagnosis of diabetes made by a health care professional. Disability was assessed via self-report. 12-Month and lifetime MDD and GAD were assessed with the Composite International Diagnostic Interview 3.0. RESULTS: In multinomial logistic regression models adjusted for sociodemographic and health-related factors, having diabetes was associated with a greater likelihood of 12-month comorbid MDD and GAD (OR=1.99, 95% CI [1.22, 3.25], p=.006), compared with those with neither MDD nor GAD. No significant associations were found for MDD without GAD or GAD without MDD. This pattern of effects held when lifetime diagnoses of MDD and GAD were considered. For individuals with diabetes (n=1730), adjusted binary logistic regression models demonstrated that with 12-month diagnoses, MDD without GAD (OR=2.79, 95% CI [1.39-5.62], p=.004), GAD without MDD (OR=3.69, 95% CI [1.34-10.11], p=.01), and comorbid MDD and GAD (OR=4.17, 95% CI [1.66-10.51], p=.002) were associated with greater disability than the control group. Only comorbid MDD and GAD were associated with disability when lifetime diagnoses of MDD and GAD were considered. CONCLUSIONS: Individuals with diabetes may be particularly vulnerable to comorbid MDD and GAD, and MDD-GAD comorbidity may exacerbate disability in persons with diabetes.

Determinants of participation in leisure activities among adolescents with cerebral palsy.

Studies have identified restrictions in engagement in leisure activities for adolescents with disabilities. Participation is a complex construct and likely influenced by a variety of factors. These potential determinants have not yet been sufficiently explored in the population of adolescents with cerebral palsy (CP). The objective of this study is to estimate the potential influence of adolescent characteristics and environmental factors as determinants of participation in leisure activities for adolescents with CP. A cross-sectional design was used. Participants were adolescents (12-19 years old) with cerebral palsy. Participants were assessed with the Vineland Adaptive Behavior Scale - II, Gross Motor Function Measure, Gross Motor Function Classification System, Manual Ability Classification System and completed the Self-Perception Profile for Adolescents, Dimensions of Mastery Questionnaire, Strengths and Difficulties Questionnaire, Family Environment Scale, the European Child Environment Questionnaire and the Preferences for Activities of Children. The main outcome measure was the Children's Assessment of Participation and Enjoyment. 187 adolescents (age M=15.4; SD=2.2) completed the study. Multivariate models of participation in leisure revealed associations with factors related to the adolescents' functional characteristics and attitudes, the family environment, socioeconomic status, and contextual factors such as school type, and collectively explained from 28% (diversity of skill-based activities) up to 48% (intensity and diversity of self-improvement activities) of the variance in intensity and diversity in five leisure participation domains (diversity: r(2)=.33 recreational; r(2)=.39 active-physical; r(2)=.33 social activities). Adolescent's mastery motivation, self-perception and behavior were individually associated with participation in different activity domains, but did not strongly predict participation within multivariate models, while preferences for activities were strong predictors of participation in all domains, except for skill-based activities. Engagement in different types of leisure activities is important for adolescents' development and well-being. Health care professionals should consider adolescents' and families' characteristics to promote participation in leisure activities.

Picture me playing-a portrait of participation and enjoyment of leisure activities in adolescents with cerebral palsy.

In recent years attention has been paid to the participation levels of children and youth with Cerebral Palsy (CP), particularly the extent to which they have the opportunity to be involved in and enjoy leisure activities. The objective of this study is to describe the level of participation and enjoyment in leisure activities among adolescents with CP and to identify potential differences in participation patterns related to sociodemographic attributes. A cross-sectional design was used. Participants were 175 adolescents 12-20 years old (M=15.3; ±2.2), GMFCS I=55/II=43/III=13/IV=18/V=39 who completed the Children's Assessment of Participation and Enjoyment (CAPE). The types of activities participants engaged in most frequently were social and recreational activities, whereas self-improvement and skill-based activities were least frequent. Social activities were the activities they enjoyed most. In general, participation decreases, as youth grow older. Girls engaged in more self-improvement activities than boys. Adolescents who study in special segregated schools experienced a lower diversity and intensity of engagement in all leisure activity domains. Adolescents who were not ambulatory and those presenting with more severe manual ability limitations participated less in all activity types except skill-based activities. Adolescents with CP place a high value on the ability to engage in activities of their own choosing and on interacting with friends. Engagement in a variety of leisure activities is important for a healthy development. Understanding the leisure patterns and preferences of this population, in addition to the contextual factors, may help in the elaboration of interventions and programs to promote a healthy development for this population.

The prevalence of mental disorders in the working population over the period of global economic crisis.

OBJECTIVES: The ongoing global economic crisis may have affected people's mental health. This study aimed to, among a sample of the working population, estimate and compare the prevalence of depressive and anxiety disorders in different time intervals from January 2008 to October 2009 and to examine the demographic and socioeconomic correlates of mental disorders. METHODS: From January 2008 to October 2009, 3579 employees in Alberta were recruited using the random digit dialing method. Mental disorders were assessed using the World Health Organization's Composite International Diagnostic Interview-Auto 2.1. The lifetime and 12-month prevalence of depressive and anxiety disorders in different time intervals were estimated and compared. RESULTS: The 12-month prevalence of major depressive disorder (MDD) before September 1, 2008; between September 1, 2008, and March 1, 2009; and between March 1, 2009, and October 30, 2009, was 5.1%, 6.8%, and 7.6% (P = 0.03), respectively. The lifetime prevalence of dysthymia reported during the 3 periods was 0.4%, 0.7%, and 1.5% (P = 0.006), respectively. No changes in the 12-month prevalence of social phobia, panic disorder, and generalized anxiety disorder were found over time. CONCLUSIONS: The ongoing global economic crisis may have contributed to the increased prevalence of MDD. Future studies are needed to monitor the changes in the prevalence and to describe how the event may affect people's employment status, income, and health.

Standard International prognostic index remains a valid predictor of outcome for patients with aggressive CD20+ B-cell lymphoma in the rituximab era.

PURPOSE: The International Prognostic Index (IPI) is widely used for risk stratification of patients with aggressive B-cell lymphoma. The introduction of rituximab has markedly improved outcome, and R-CHOP (rituximab + cyclophosphamide, doxorubicin, vincristine, prednisone) has become the standard treatment for CD20(+) diffuse large B-cell lymphoma. To investigate whether the IPI has maintained its power for risk stratification when rituximab is combined with CHOP, we analyzed the prognostic relevance of IPI in three prospective clinical trials. PATIENTS AND METHODS: In total, 1,062 patients treated with rituximab were included (MabThera International Trial [MInT], 380 patients; dose-escalated regimen of cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisone (MegaCHOEP) trial, 72 patients; CHOP + rituximab for patients older than age 60 years [RICOVER-60] trial, 610 patients). A multivariate proportional hazards modeling was performed for single IPI factors under rituximab on event-free, progression-free, and overall survival. RESULTS: IPI score was significant for all three end points. Rituximab significantly improved treatment outcome within each IPI group resulting in a quenching of the Kaplan-Meier estimators. However, IPI was a significant prognostic factor in all three end points and the ordering of the IPI groups remained valid. The relative risk estimates of single IPI factors and their order in patients treated with R-CHOP were similar to those found with CHOP. CONCLUSION: The effects of rituximab were superimposed on the effects of CHOP with no interactions between chemotherapy and antibody therapy. These results demonstrate that the IPI is still valid in the R-CHOP era.

Association between neighborhood-level deprivation and disability in a community sample of people with diabetes.

OBJECTIVE: The objective of the present study was to analyze the association between neighborhood deprivation and self-reported disability in a community sample of people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Random digit dialing was used to select a sample of adults with self-reported diabetes aged 18-80 years in Quebec, Canada. Health status was assessed by the World Health Organization Disability Assessment Schedule II. Material and social deprivation was measured using the Pampalon index, which is based on the Canadian Census. Potential risk factors for disability included sociodemographic characteristics, socioeconomic status, social support, lifestyle-related factors (smoking, physical activity, and BMI), health care-related problems, duration of diabetes, insulin use, and diabetes-specific complications. RESULTS: There was a strong association between disability and material and social deprivation in our sample (n = 1,439): participants living in advantaged neighborhoods had lower levels of disability than participants living in disadvantaged neighborhoods. The means +/- SD disability scores for men were 7.8 +/- 11.8, 12.0 +/- 11.8, and 18.1 +/- 19.4 for low, medium, and high deprivation areas, respectively (P < 0.001). The disability scores for women were 13.4 +/- 12.4, 14.8 +/- 15.9, and 18.9 +/- 16.2 for low, medium, and high deprivation areas, respectively (P < 0.01). Neighborhood deprivation was associated with disability even after controlling for education, household income, sociodemographic characteristics, race, lifestyle-related behaviors, social support, diabetes-related variables, and health care access problems. CONCLUSIONS: The inclusion of neighborhood characteristics might be an important step in the identification and interpretation of risk factors for disability in diabetes.

A multisite Canadian study of outcome of first-episode psychosis treated in publicly funded early intervention services.

OBJECTIVE: The aim of this study was to determine 1-year symptomatic outcome and its predictors in patients with FEP treated at 3 different publicly funded sites. METHOD: We evaluated FEP patients (n = 172) treated in specialized programs in 2 medium-sized centres and 1 large urban centre with an identical protocol for demographic variables, diagnosis, and duration of untreated psychosis (DUP) at entry, and positive, negative, and general psychopathology symptoms at entry, 6 months, and 1 year. We used a mixed model analysis of variance, with time and centre and interaction between time and centre as fixed effects and sex and DUP as covariates, to analyze data. RESULTS: A significant effect of time and time x centre interaction on positive, negative, and general symptom outcome was shown after controlling for ethnicity, education, and diagnosis. Patients showed significantly better outcome on all dimensions of symptoms in the 2 medium-sized centres, compared with the 1 large urban centre. Sex had a significant effect on negative and general symptoms, while DUP had no effect on any outcome measure. CONCLUSIONS: Similarly enriched EI services may produce different outcomes, even within a relatively homogeneous mental health system.

Validation of the English and French versions of the Community Assessment of Psychic Experiences (CAPE) with a Montreal community sample.

OBJECTIVE: The aim of this study was to examine the reliability, validity and factor structure of the Community Assessment of Psychic Experiences (CAPE), a 42-item self-report questionnaire. We analyzed the internal consistency of the CAPE to determine whether the 3-factor structure (positive, negative and depressive symptoms) found by the CAPE authors would also be found in our sample. METHOD: A sample of 2275 individuals from the general community in the Montreal area completed the questionnaire in either French or English. RESULTS: The internal consistencies of the original three subscales were good and the confirmatory factor models had a good fit. The exploratory factor analysis suggested a 3-5-factor solution, without improving the alternative factor structures. The 4-factor solution separated positive symptoms into factors we called 'bizarre positive symptoms' and 'social delusions', and the 5-factor solution separated positive symptoms further and included a 'popular psychic beliefs' factor. Results suggest that the scalability might be improved by shortening the original questionnaire to 23 items with the same 3 original scales. CONCLUSION: We support the internal consistency of the CAPE. Although alternative scaling (4 and 5 factors) did not improve the model fit, researchers interested in distinguishing 3 factors of positive symptoms could find utility in these two new scales. Finally, reducing the number of CAPE items could be useful for shorter surveys. Future studies should test the implications of these suggestions.

The SF-36 summary scores and their relation to mental disorders: physical functioning may affect performance of the summary scores.

BACKGROUND AND OBJECTIVES: The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) has been widely used as a generic measure of health status. It can be scored to provide either a profile of eight scores or two summary measures of health. Several studies demonstrated shortcomings of the summary scores in accurately reflecting patients' physical and mental health on the basis of subscale scores. The objective of this study was to compare and evaluate different scoring algorithms for the summary scores. METHODS: The analysis was based on data on 4,052 respondents from the German National Health Interview and Examination Survey. Mental disorders were assessed using a structured clinical interview. Logistic regression and receiver operating characteristic analyses were used to evaluate the association between the mental component scores and mental disorders. RESULTS: Subjects with mental disorders reported poorer quality of life on all SF-36 subscales and component scores compared to those without mental disorders. The presence of physical disorders resulted in different summary scores. The screening accuracy in detecting subjects with mental disorders was satisfactory for both mental summary scores. CONCLUSIONS: The summary scores should be evaluated in relation to the profile of the eight subscales. Physical functioning should be evaluated carefully when comparing health status using summary scores.

Impact of a specialized early intervention service for psychotic disorders on patient characteristics, service use, and hospital costs in a defined catchment area.

OBJECTIVE: To evaluate the impact of a new early intervention service for first-episode psychosis on patient characteristics, service use, and hospital costs. METHOD: We examined clinical records of all first admissions to hospitals of patients diagnosed with first-episode psychoses (nonaffective) over a 3-year period before and after the introduction of an early intervention service, the Prevention and Early Intervention Program for Psychosis (PEPP), in a defined catchment area. We examined demographic, clinical, and service use indices covering a 2-year period subsequent to the index admission for each patient. RESULTS: Patients in the post-PEPP phase were significantly younger (P < 0.01), were more often male (P < 0.05), and were less likely to be admitted to hospital with an involuntary status (P < 0.05) or with injuries (P < 0.05) at the time of their first hospital admission. Over the 2 years following the initial admission, post-PEPP patients had significantly fewer admissions to a regular psychiatric service (P < 0.001) and made significantly fewer visits to the hospital emergency department (P < 0.01). There was a significant mean reduction in costs per case of regular hospital bed use ($1028.49, SD 528.02, compared with $792.28, SD 528.02; P < 0.01) and emergency visits ($519.18, SD 353.79, compared with $353.79, SD 345.0; P < 0.01). Time series analyses followed by Chow tests failed to confirm that these cost changes could be attributed specifically to the introduction of an early intervention service. CONCLUSION: Introduction of a specialized early intervention program may be beneficial to patients and to the health care system. To evaluate the cost-benefit ratio of early intervention services, longer term and more detailed data may be required.