Development of a framework for prospective payment for child mental health services.

OBJECTIVES: There is a need to develop a payment system for services for children with mental health problems that allows more targeted commissioning based on fairness and need. This is currently constrained by lack of clinical consensus on the best way forward, wide variation in practice, and lack of data about activity and outcomes. In the context of a national initiative in England our aim was to develop a basis for an improved payment system. METHODS: Three inter-related studies: a qualitative consultation with child and adolescent mental health services (CAMHS) stakeholders on what the key principles for establishing a payment system should be, via online survey (n = 180) and two participatory workshops (n = 91); review of relevant national clinical guidelines (n = 15); and a quantitative study of the relationship between disorders and resource use (n = 1774 children from 23 teams). RESULTS: CAMHS stakeholders stressed the need for a broader definition of need than only diagnosis, including the measurement of indirect service activities and appropriate outcome measurement. National clinical guidance suggested key aspects of best practice for care packages but did not include consideration of contextual factors such as complexity. Modelling data on cases found that problem type and degree of impairment independently predicted resource use, alongside evidence for substantial service variation in the allocation of resources for similar problems. CONCLUSIONS: A framework for an episode-based payment system for CAMHS should include consideration of: complexity and indirect service activities; evidence-based care packages; different needs in terms of impairment and symptoms; and outcome measurement as a core component.

Dimensions of positive symptoms in late versus early onset psychosis.

BACKGROUND: Casenote studies have characterized late onset schizophrenia (LOS) and related psychoses as somewhat different symptomatically from patients with an early onset schizophrenia (EOS). This study examined a range of phenomenological aspects of delusions and hallucinations as well as traditional symptom measures in both groups. METHODS: 34 LOS and 235 EOS completed the Positive and Negative Syndrome Scale, the Psychotic Symptom Rating Scales, and the Beck Depression and Anxiety inventories. Subgroups experiencing delusions were compared matching for chronological age and gender, and also when matched for chronicity and gender. RESULTS: Delusions were very common at over 80% in both groups. LOS participants with delusions exhibited greater suspiciousness/paranoia, greater belief-conviction, and reduced insight when compared with the EOS group. These findings remained when matching for chronicity of illness, but disappeared when matching for chronological age. Hallucinations were surprisingly rarer in LOS (35%) than EOS (57%), with half the LOS group reporting whispers rather than clearly audible sounds. In general, anxiety, depression, and distress were as marked in LOS and EOS. CONCLUSIONS: Similarities between EOS and LOS far outweighed the differences across a range of symptoms and measures. Greater delusional conviction, paranoia, and poorer insight in LOS were associated with the later age of onset rather than relating to chronicity of illness. As belief-conviction in LOS was not associated with increased grandiosity, disorientation, or unusualness of thought content, as it was in EOS, delusional conviction may be determined somewhat differently later in life.

Predictors of psychological morbidity in liver transplant assessment candidates: is alcohol abuse or dependence a factor?

Orthotopic liver transplantation candidates with depressive and other symptoms report poorer perceived quality of life when compared with nondepressed patients, and are also significantly more likely to die while awaiting transplantation. Alcohol abuse and dependence have been associated with increased levels of psychological co-morbidity. This article presents data about psychological morbidity from a prospective study of patients being assessed for liver transplantation in Birmingham, UK, and explores whether those with a diagnosis of alcohol abuse or dependence are at increased risk of psychological symptoms. Of 399 consecutive patients assessed for liver transplantation between July 2004 and July 2005, a sample of 155 was included in the study. Eighty-three (53.5%) patients were identified as having general psychological distress that merited referral for specialist assessment using the Symptom Checklist-90-Revised instrument. The alcohol-dependent group achieved the highest overall 'caseness' rates, with 72% (n = 26) compared with 52% (n = 12) of the alcohol-abuse group and 47% (n = 45) of those with no alcohol-related diagnosis. However, alcohol abuse or dependence was not the significant predictor of psychological symptoms in the final regression model. Higher rates of psychological distress were associated with greater severity of liver disease, being unemployed, and being a tobacco smoker. Possible reasons for these findings and potential future management strategies are discussed.

Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure.

Transplantation for alcoholic liver disease is becoming increasingly common, and with adequate screening, short- to medium-term outcomes are very good. However, while conducting a prospective study of the outcome of liver transplantation in Birmingham, United Kingdom, we observed that a research diagnosis of alcohol abuse or dependence was made in a number of cases in which no reference to alcohol problems had been made by the referring agency. This article explores the characteristics of these "missed" cases and highlights key patient characteristics that might prompt a more detailed assessment of alcohol consumption. Two hundred eight individuals completed the research interview, and 80 (39%) met Diagnostic and Statistical Manual of Mental Disorders IV criteria for a lifetime diagnosis of either alcohol abuse (n = 29) or dependence (n = 51). When the initial referral details were reviewed, the possibility of alcohol problems had not been raised in 10 (12.5%) of these cases. Hepatitis C was the most common primary diagnosis in the missed cases, but there was no difference between diagnosed and missed cases in terms of demographic factors, severity of liver disease, or the number or degree of lifetime problems associated with alcohol. However, members of the missed group were more likely to have drunk alcohol in the past 6 months and in a greater volume and were more likely to have used illicit drugs such as opiates, amphetamines, hallucinogens, and cannabis. These findings point to the need to take an adequate history of lifetime alcohol problems in all patients being considered for liver transplantation.

Mapping heroin careers: utilising a standardised history-taking method to assess the speed of escalation of heroin using careers in a treatment-seeking cohort.

INTRODUCTION AND AIMS: Although there has been increasing research attention to the concept of addiction careers and treatment careers, there are few standardised measures for assessing illicit drug using careers. A new instrument for mapping lifetime drug use history (LDUH) was used to assess transitions in the initial stages of heroin use careers among illicit drug users. DESIGN AND METHODS: 58 lifetime heroin users completed a one-off researcher-administered interview in treatment settings in two English cities, London and Birmingham, about their histories of drug use, drug treatment and other key life events. RESULTS: The sample reported initiating heroin use at a mean age of 21 years and escalated to daily use by 23 years. On average, there was a gap of nearly 8 years before seeking treatment and at the time of interview the cohort averaged one-third of their heroin careers in treatment. However, there was marked variability across the group, with three discernible groups identified based on use patterns. While one group (n = 21) showed consistent escalation in total quantity of heroin used across the first year, the second group had an intermittent pattern of use and the third group reported an unchanging monthly heroin use pattern. These groups differed in the time taken to initiate treatment and in the proportion of their heroin careers in active use. DISCUSSION AND CONCLUSIONS: The instrument was acceptable to research participants and identified important variability in onset and escalation factors in heroin careers. The implications for therapeutic interventions and for clinical use of the instrument are discussed.