Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design

BACKGROUND:At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK. RESEARCH QUESTIONS:(1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention? METHODS:We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial. RESULTS:Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’s d = 0.34), after 6 months (Cohen’s d = 0.29) and after 12 months (Cohen’s d = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs. LIMITATIONS:The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings. CONCLUSIONS:(1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life. FUTURE RESEARCH:Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression. TRIAL REGISTRATION:Current Controlled Trials ISRCTN34757603. FUNDING:The National Institute for Health Research Programme Grants for Applied Research programme

Bilingual episodic memory: an introduction

Our current models of bilingual memory are essentially accounts of semantic memory whose goal is to explain bilingual lexical access to underlying imagistic and conceptual referents. While this research has included episodic memory, it has focused largely on recall for words, phrases, and sentences in the service of understanding the structure of semantic memory. Building on the four papers in this special issue, this article focuses on larger units of episodic memory(from quotidian events with simple narrative form to complex autobiographical memories) in service of developing a model of bilingual episodic memory. This requires integrating theory and research on how culture-specific narrative traditions inform encoding and retrieval with theory and research on the relation between(monolingual) semantic and episodic memory(Schank, 1982; Schank & Abelson, 1995; Tulving, 2002). Then, taking a cue from memory-based text processing studies in psycholinguistics(McKoon & Ratcliff, 1998), we suggest that as language forms surface in the progressive retrieval of features of an event, they trigger further forms within the same language serving to guide a within-language/ within-culture retrieval

Institutional Capacity to Respond to the Ethical Challenges of Patient Sexual Expression in State Psychiatric Hospitals in the United States

Patient sexual expression in psychiatric institutions is a major clinical and administrative challenge. For this study, hospital facility directors were surveyed and asked about the existence and nature of formal policies regarding patient sexuality-related needs and staff preparedness to handle various forms of patient sexual expression. Consistent with prior studies, the survey fi ndings show formal policies tend to enforce a punitive response to sexual behavior. More important, the results also reveal a workforce poorly prepared to negotiate the complex ethical issues that arise in addressing patient sexual expression in state psychiatric institutions in the U.S

The Pracademic and Academic in Criminal Justice Education: A Qualitative Analysis

Over the past several years, a few hundred colleagues involved in criminal justice education have participated in panel discussions and roundtables to discuss the trials and issues that have been observed by practitioners turned academics, or “pracademics.” Some complained of having difficulty breaking into academia. A debate has occurred in a number of colleges and universities over the benefit of having faculty with traditional academic credentials versus hiring non-traditional scholars with a blend of educational and practical experience. Similarly, there have been lively discussions over the appropriateness of a J.D. or professional doctorate as opposed to a Ph.D. in criminal justice. This debate started in an article in ACJS Today (2002) and continued in subsequent publications. It is believed that there is importance, benefit and relevance to incorporating practical experience on college and university campuses. In academic program after program, internships, externships, observation, and practicums have become essential in preparing students for the real world

ASSOCIATING SNPS WITH BINARY TRAITS

Association mapping uses statistical analyses to test for relationships between genomic markers called single nucleotide polymorphisms (SNPs) and traits. This research focuses on the use of logistic regression to assess the additive, dominance, and epistatic effects when investigating associations between SNPs and binary traits, such as disease status. A very specific phenomenon that results in infinite maximum likelihood estimates (MLEs) of logistic regression parameters, called quasi-separation of points (QSP), is investigated. We provide a solution that relies on the use of Firth’s MLE to estimate logistic regression parameters. Simulated and real data are utilized to investigate the use of Firth’s MLE in a QSP setting

The future of Earth observation in hydrology

In just the past 5 years, the field of Earth observation has progressed beyond the offerings of conventional space-agency-based platforms to include a plethora of sensing opportunities afforded by CubeSats, unmanned aerial vehicles (UAVs), and smartphone technologies that are being embraced by both for-profit companies and individual researchers. Over the previous decades, space agency efforts have brought forth well-known and immensely useful satellites such as the Landsat series and the Gravity Research and Climate Experiment (GRACE) system, with costs typically of the order of 1 billion dollars per satellite and with concept-to-launch timelines of the order of 2 decades (for new missions). More recently, the proliferation of smart-phones has helped to miniaturize sensors and energy requirements, facilitating advances in the use of CubeSats that can be launched by the dozens, while providing ultra-high (3-5 m) resolution sensing of the Earth on a daily basis. Start-up companies that did not exist a decade ago now operate more satellites in orbit than any space agency, and at costs that are a mere fraction of traditional satellite missions. With these advances come new space-borne measurements, such as real-time high-definition video for tracking air pollution, storm-cell development, flood propagation, precipitation monitoring, or even for constructing digital surfaces using structure-from-motion techniques. Closer to the surface, measurements from small unmanned drones and tethered balloons have mapped snow depths, floods, and estimated evaporation at sub-metre resolutions, pushing back on spatio-temporal constraints and delivering new process insights. At ground level, precipitation has been measured using signal attenuation between antennae mounted on cell phone towers, while the proliferation of mobile devices has enabled citizen scientists to catalogue photos of environmental conditions, estimate daily average temperatures from battery state, and sense other hydrologically important variables such as channel depths using commercially available wireless devices. Global internet access is being pursued via high-altitude balloons, solar planes, and hundreds of planned satellite launches, providing a means to exploit the "internet of things" as an entirely new measurement domain. Such global access will enable real-time collection of data from billions of smartphones or from remote research platforms. This future will produce petabytes of data that can only be accessed via cloud storage and will require new analytical approaches to interpret. The extent to which today's hydrologic models can usefully ingest such massive data volumes is unclear. Nor is it clear whether this deluge of data will be usefully exploited, either because the measurements are superfluous, inconsistent, not accurate enough, or simply because we lack the capacity to process and analyse them. What is apparent is that the tools and techniques afforded by this array of novel and game-changing sensing platforms present our community with a unique opportunity to develop new insights that advance fundamental aspects of the hydrological sciences. To accomplish this will require more than just an application of the technology: in some cases, it will demand a radical rethink on how we utilize and exploit these new observing systems

Practical long-distance quantum key distribution system using decoy levels

Quantum key distribution (QKD) has the potential for widespread real-world applications. To date no secure long-distance experiment has demonstrated the truly practical operation needed to move QKD from the laboratory to the real world due largely to limitations in synchronization and poor detector performance. Here we report results obtained using a fully automated, robust QKD system based on the Bennett Brassard 1984 protocol (BB84) with low-noise superconducting nanowire single-photon detectors (SNSPDs) and decoy levels. Secret key is produced with unconditional security over a record 144.3 km of optical fibre, an increase of more than a factor of five compared to the previous record for unconditionally secure key generation in a practical QKD system.Comment: 9 page