Good friends are hard to find? The social networks of people with mental illness 12 years after deinstitutionalisation.

BACKGROUND: While community care is now well established in England, the development and maintenance of social networks of people with long-term mental illness remains a major challenge to services. AIMS: To investigate the size of the social networks of people with long-term mental illness and the types of social support they receive in relation to their age and accommodation. Sample Thirty-nine men and 46 women (mean age: 61 years; range: 38-88). Forty nine (60%) were 65 years or under and 32 (40%) were over 65. METHODS: Participants were interviewed using the Social Network Guide. Comparisons were made using generalised linear modelling. RESULTS: Social networks (median 19; range 2-85) were generally larger than those reported in previous studies. Older residents (over 65 years) had closer ties than younger residents. Congregate types of community settings were relatively devoid of social supports. CONCLUSION: Appropriate activities and social contexts are still needed to facilitate the social networks of people with mental illness, in particular, for those aged under 65 years.

Predictors of outcomes of assertive outreach teams: a 3-year follow-up study in North East England.

INTRODUCTION: Assertive outreach (AO) is a required component of services for people with severe mental illness in England. However, the claims to its effectiveness have been contested and the relationships between team organisation, including model fidelity, the use of mental health interventions and outcomes for service users remain unclear. METHOD: Three-year follow up of 33 AO teams was conducted using standardised measures of model fidelity and mental health interventions, and of current location and a range of outcomes for service users (n = 628). Predictors of the number of hospital admissions, mental health and social functioning at T2, and discharge from the team as 'improved' were modelled using multivariate regression analyses. RESULTS: Teams had moderate mean ratings of fidelity to the AO model. All rated highly on the core intervention modalities of engagement, assessment and care co-ordination, but ratings for psychosocial interventions were comparatively low. Two-thirds (462) of service users were still in AO and data were returned on 400 (87%). There was evidence of small improvements in mental health and social functioning and a reduction in the mean number of hospital admissions in the previous 2 years (from 2.09 to 1.39). Poor outcomes were predicted variously by service users' characteristics, previous psychiatric history, poor collaboration with services, homelessness and dual diagnosis. Fidelity to the AO model did not emerge as a predictor of outcome, but the team working for extended hours was associated with more frequent in-patient admissions and less likelihood of discharge from AO. Supportive interventions in daily living, together with the team's use of family and psychological interventions were also associated with poorer outcomes. Possible explanations for these unexpected findings are considered. CONCLUSION: AO appears to have been quite successful in keeping users engaged over a substantial period and to have an impact in supporting many people to live in the community and to avoid the necessity of psychiatric hospital admission. However, teams should focus on those with a history of hospital admissions, who do not engage well with services and for whom outcomes are less good. Psychosocial interventions should be applied. The relationship between model fidelity, team organisation, mental health interventions and outcomes is not straightforward and deserves further study.

Functional defecation disorder as a clinical subgroup of chronic constipation: analysis of symptoms and physiological parameters.

OBJECTIVE: Patients with functional constipation can be classified according to symptoms and physiological parameters as either having a disorder of defecation or having normal defecation. It is hypothesized that the disordered defecation, where it exists, is a causative factor of the constipation. However, the utility of this classification has yet to be proven in terms of predicting response to therapy. The definitions are non-specific and based on tests that are done in an artificial setting and with derived normal ranges. It is therefore possible that the symptoms and physiological parameters of a defecatory disorder may occur as a continuous spectrum in these patients, rather than defining a discrete entity or subtype. The aim of this study was to use cluster analysis and factor analysis of defecatory symptoms and physiological parameters to look for evidence of subgroups in patients with functional constipation. MATERIAL AND METHODS: Consecutive patients presenting to a specialist constipation clinic and satisfying the inclusion criteria were assessed to determine the severity of defecatory symptoms, and underwent isotope defecating proctography and the Sitzmark transit study. Assessments were made contemporaneously and results of any test not performed within 6 weeks of the initial assessment were excluded. Principle components analysis and cluster analysis were performed to look for evidence of subgroups. Relationships between evacuatory symptoms, index parameters, and test results were explored. The detailed and unselected nature of the analyses produced hundreds of test results, and statistically significant results were critically evaluated in this context. RESULTS: A total of 116 patients were studied (age range 18-73 years, mean 40.5 years). Based on the results of the transit study and proctography, 38% of patients showed evidence of slow transit constipation, 20% FDD (functional defecation disorder), 29% both, and 12% neither. Principle components analysis did not demonstrate an obvious dimension reduction for the variables tested. Cluster analysis (over 150 solutions tested) failed to show evidence of clustering. There were no useful predictive relationships between evacuatory symptoms, index parameters and test results. CONCLUSIONS: We used multiple statistical analyses to look for clustering and predictive relationships between clinical and physiological parameters in consecutive patients with functional constipation and found no evidence of the existence of a subgroup of patients with a defecatory disorder. This may be due to weaknesses in the study design, poor validity of the assessments performed, or that defecatory features do not identify a distinct pathophysiological entity, but rather are manifested variably as a continuous spectrum.

Correlation models for monitoring child growth.

Growth measurements of children, such as weight and height, are monitored regularly, particularly in infancy, to assess whether or not a child's growth is normal when compared with a reference population of the same age and sex. Here, after a suitable power transformation to normality of the reference population, we model temporal evolution of the standardized deviation (Z-score) of the transformed measurement of a normal child from the reference population as a Gaussian process with zero mean and unit variance. This paper concentrates on modelling and fitting the serial correlation structure of the process, with the benefit that monitoring growth at specific ages is not crucial, statistically. Exploratory analysis of various observed correlation matrices has suggested that a particular two-parameter Markovian form is a good representation of the correlation function in infancy. The main implication for growth monitoring is that we only need to condition on the most recent Z-score to inform a clinician's judgement about a child's growth based on its current Z-score. Inferences about the correlation parameters derive from likelihood methods based either on observed Z-scores or, if raw data are unavailable, on an observed correlation matrix. The Markov model is compared with a previously studied six-parameter correlation model. Data from major child growth studies in Newcastle and Cambridge are used to illustrate the methods and compare predictions from the two models. We argue that the Markov model serves as a pragmatic choice for growth monitoring in infancy.

Outcomes of interprofessional education for Community Mental Health Services in England: the longitudinal evaluation of a postgraduate programme.

We report a comprehensive, longitudinal evaluation of a two-year, part-time postgraduate programme designed to enable health and social care professionals in England to work together to deliver new community mental health services, including psychosocial interventions (PSIs). The study tracked three successive cohorts of students (N = 111) through their learning. Outcomes were assessed according to the Kirkpatrick/Barr et al. framework using a mixed methodology, which employed both quantitative measures and interviews. The students evaluated the programme positively and appreciated its focus on interprofessional learning and partnership with services users, but mean levels of stress increased and almost one quarter dropped out. There was considerable evidence of professional stereotyping but little evidence of change in these during the programme. Students reported substantial increases in their knowledge and skills in multidisciplinary team working and use of PSIs (p < 0.001). Experiences in the implementation of learning varied; in general, students reported significantly greater role conflict (p = 0.01) compared to a sample of their team colleagues (N = 62), but there was strong evidence from self-report measures (p < 0.001) and work-place interviews that the students' use of PSIs had increased. Users with severe mental health problems (N = 72) randomly selected from caseloads of two cohorts of students improved over six months in terms of their social functioning (p = 0.047) and life satisfaction (p = 0.014). Having controlled statistically for differences in baseline score, those in the intervention (programme) group retained a significant advantage in terms of life skills (p < 0.001) compared to service users in two non-intervention comparison groups (N = 133). Responses on a user-defined measure indicated a high level of satisfaction with students' knowledge, skills and personal qualities. We conclude that that there is strong evidence that a well-designed programme of IPE can be effective in helping students to learn new knowledge and skills, and to implement their learning in the workplace. Further, we consider that there is some modest evidence of the benefits of such learning for service users.

A needs index for mental health care in England based on updatable data.

BACKGROUND: Mathematical models relating rates of mental health care use to population characteristics such as social deprivation are widely used in both planning and researching mental health services. The models currently in wide use in England are based on data mostly derived from the 10-yearly population censuses. These are perceived to be out of date many years before new census data are available for their replacement. A new set of government deprivation monitoring statistics based mainly on annually updatable data has recently been developed. This study set out to produce a mental illness needs index based on these new data. METHODS: A series of regression models were tested using individual domain scores from the DETR Index of Multiple Deprivation and the Office of National Statistics area-type classification as independent variables to predict 1998/9 psychiatric admission rates for broad diagnostic groups for 8251 of the 8414 electoral wards in England as dependent variables. RESULTS: The distribution of admission numbers in wards showed a pattern of over-dispersion with an excessive number of zero values for conventional regression approaches. A two-stage 'hurdle' model was, thus, adopted, predicting first the likelihood that wards would produce any admissions and second the probable number. This produced satisfactory predictive power, with residual variance showing strong geographical patterns associated with administrative areas, probably arising from differential resourcing or idiosyncratic clinical practice. CONCLUSIONS: A website providing data on the various indicators has been provided and its uses are indicated.

Prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease: systematic review.

OBJECTIVES: To ascertain the prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease and its association with the disease. DESIGN: Systematic review of studies reporting the prevalence of H pylori in patients with and without gastro-oesophageal reflux disease. DATA SOURCES: Four electronic databases, searched to November 2001, experts, pharmaceutical companies, and journals. MAIN OUTCOME MEASURE: Odds ratio for prevalence of H pylori in patients with gastro-oesophageal reflux disease. RESULTS: 20 studies were included. The pooled estimate of the odds ratio for prevalence of H pylori was 0.60 (95% confidence interval 0.47 to 0.78), indicating a lower prevalence in patients with gastro-oesophageal reflux disease. Substantial heterogeneity was observed between studies. Location seemed to be an important factor, with a much lower prevalence of H pylori in patients with gastro-oesophageal reflux disease in studies from the Far East, despite a higher overall prevalence of infection than western Europe and North America. Year of study was not a source of heterogeneity. CONCLUSION: The prevalence of H pylori infection was significantly lower in patients with than without gastro-oesophageal reflux, with geographical location being a strong contributor to the heterogeneity between studies. Patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from western Europe and North America, despite a higher prevalence in the general population.

Correlates of stress in carers.

BACKGROUND: Mental health services are required to take account of the needs of carers, yet little is known about how services affect carers. AIMS: This paper explores the relationship between the user's mental health problems, the services received and the impact of caring on carers. METHODS: Sixty-four carers were interviewed, measuring their experiences of care-giving, carer stress and the service user's level of impairment. A robust, composite measure of user severity was derived. RESULTS: Carers were sometimes better judges than care co-ordinators of user impairment. Their experience reflected the independently rated severity of service users' problems. When carers were aware of care plans, they felt less negative about caring. Even in above-average mental health services, carers lacked information about: care plans, medication and complaints procedures. CONCLUSIONS: This evidence can be used in allocating resources such respite care, family therapy and CBT to carers. These findings have implications for how mental health services might improve their provision for carers, for instance, involvement in care planning may help carers to cope.

Community mental healthcare in England: associations between service organisation and quality of life.

The present authors set out to explore the relationship between different forms of service organisation and quality of life (QoL) for service users. Four mental health trusts and their corresponding social services departments were recruited to exemplify: (1). high and low levels of integration between health and social services; and (2). high and low levels of targeting at users with severe mental health problems. The authors used the Lancashire Quality of Life Profile, and chose their sample size to be able to detect a difference of 0.5 in subjective satisfaction scales. Analysis of covariance was used to investigate the simultaneous impact of variables representing user characteristics, objective and subjective QoL, and service organisation. Two hundred and sixty users selected at random from the active caseloads of mental health services in the four districts were interviewed at time 1 and 232 people were interviewed 6 months later (time 2). No bias was detected in the non-respondents at time 2. The authors found few differences between districts. As in other similar studies, QoL seemed to be stable for the whole sample over time. In 6 months, general satisfaction with leisure increased and the number of people who had been in hospital fell. Negative affect score was the only variable found to be associated with subjective QoL, and no predictors of objective QoL were identified. There was some evidence of better objective outcomes for people in receipt of integrated mental health services. They socialised more, and seemed to have less difficulty accessing police and legal services. The results also suggest that interventions targeted at negative affect could have benefits for subjective QoL.

Service organisation, service use and costs of community mental health care.

BACKGROUND: Different forms of service organisation may be expected to affect costs. I is important to understand the distribution of costs amongst providers of mental health care, so that the effect of service developments on budgets can be better anticipated and planned. AIMS: This study explored the association between different forms of mental health service organisation and costs. It tested the impact on costs of services with high degrees of integration between health and social care providers, and of services targeting at people with more severe mental health problems. METHODS: 260 service users in 4 districts in the north of England were interviewed and costs identified for each person. The districts comprised examples of four types of service configuration. Use and non-use was compared by type of service, and after suitable transformations, costs were also compared between districts and between types of service. The sample was large enough to discern a difference of 50 ( 80) per week with 80% power and 5% significance. RESULTS: Costs were closely related to severity. People in targeted services had higher mean costs ( 136, SD 191 versus 92, SD 106; p=0.001). The costs of targeted services in this study were very similar to those of psychosis-only services in a London study. Integrated services were predicted to have lower inpatient costs (p=0.003), lower PCG costs (p=0.003) and lower total health and social care costs (p=0.024). Differences between use and costs of specific services were largely attributable to imprecise definitions and supply-side factors. DISCUSSION: While the sample is not representative, the a priori distinctions made in selecting the districts were reflected in service use and costs. This study suggests strongly that targeting services at people with more severe mental health problems seems likely to increase mean health and social care costs per service user. It also suggests that integration maybe associated with lower costs. Since both targeting and integration are increasingly common mental health policies, it is important to recognise that they may have opposing effects on costs.