Evaluating care pathways for community psychiatry in England: a qualitative study.

OBJECTIVES: In view of forthcoming 'payment by results' (PbR) for mental health, increasing number of National Health Service (NHS) Trusts are reorganizing their community services for working age adults to create care pathways. However, research base for the care pathways model in mental health is limited. Our NHS Foundation Trust was one of the first to introduce care pathways for community psychiatry in the UK. We have carried out a qualitative study to evaluate how this model works out in practice, including its impact on quality of patient care, mental health professionals and primary care. METHODS: We interviewed doctors, multidisciplinary staff and Trusts managers (19 in total). Transcripts of recorded interviews were coded and analysed thematically using a grounded theory approach. RESULTS: Overall, despite teething problems, working in pathways was generally seen as a positive change. It led to more focused interventions being offered, and practitioners being held to account over clear standards of care. It is more cost-effective and allows for active case management and clear clinical leadership. It is recovery focused and encourages social inclusion. The arbitrary time frame, strict criteria and thresholds for different teams can create issues. Improved communication, flexible and patient-centred approach, staff supervision, and increasing support to primary care were felt to be central to this model working efficiently and effectively. CONCLUSIONS: Introduction of care pathways is an important step towards effective implementation of PbR for mental health. Our study would inform future research into care pathways, facilitate organizational learning and help to improve effectiveness of services.

Effects of modafinil on emotional processing in first episode psychosis.

BACKGROUND: Emotional impairments are important determinants of functional outcome in psychosis, and current treatments are not particularly effective. Modafinil is a wake-promoting drug that has been shown to improve emotion discrimination in healthy individuals and attention and executive function in schizophrenia. We aimed to establish whether modafinil might have a role in the adjuvant treatment of emotional impairments in the first episode of psychosis, when therapeutic endeavor is arguably most vital. METHODS: Forty patients with a first episode of psychosis participated in a randomized, double-blind, placebo-controlled crossover design study testing the effects of a single dose of 200 mg modafinil on neuropsychological performance. Emotional functions were evaluated with the emotional face recognition test, the affective go-no go task, and the reward and punishment learning test. Visual analogue scales were used throughout the study to assess subjective mood changes. RESULTS: Modafinil significantly improved the recognition of sad facial expressions (z = 2.98, p = .003). In contrast, there was no effect of modafinil on subjective mood ratings, on tasks measuring emotional sensitivity to reward or punishment, or on interference of emotional valence on cognitive function, as measured by the affective go-no go task. CONCLUSIONS: Modafinil improves the analysis of emotional face expressions. This might enhance social function in people with a first episode of psychosis.