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

Scottish theme towns: have new identities enhanced development?

Three small towns in southwest Scotland have recently been branded as distinct theme towns, based on books, artists and food. This is an attempt to make them more attractive to visitors and thereby improve their economy. The objective of this research is to establish whether the new identities possessed by the towns have enhanced their development. It is argued, using data reviewing the past decade, that they have all developed, albeit at different rates, in terms of the economy and culture. Moreover, it is maintained that social capital has been enhanced and is a factor whose importance has been under-appreciated by planners and observers of this type of process. The relevance of the new identity to the pre-branding identity is also seen as a factor in successful development and ideas of authenticity and heritage are brought to bear on the relationship

Impact of healthcare strikes on patient mortality: a protocol for a systematic review and meta-analysis of observational studies

Introduction: A strike is a collective, temporary and calculated action, which involves a temporary stoppage of work. For healthcare professionals strike action poses a unique dilemma. Perhaps most fundamentally, as strike action is designed to be disruptive it has the potential to impact the delivery of care and place patient well-being in jeopardy. The objective of this study is therefore to evaluate the impact of healthcare strike action on patient mortality outcomes globally using meta-analysis in order to provide a comprehensive evidence base that can advise healthcare professionals, governments and regulatory bodies on the impact that strike action has on patients. Methods and analysis: A comprehensive literature search of major electronic databases (EMBASE, MEDLINE, CINAHL, BIOETHICSLINE, EconLit, WEB OF SCIENCE, OPEN GREY and SIGMA REPOSITORY) will be undertaken to identify observational studies of strike action among healthcare professionals where in-hospital/clinic and population/ community mortality is examined, prestrike, during and poststrike. Meta-analysis will be performed to estimate in-hospital/clinic and population/community mortality during periods of strike action. The quality of evidence will be assessed using the National Institute of Health quality assessment tool for observational cohort and crosssectional studies. Risk of bias will be assessed using the Cochrane Risk Of Bias In Non-Randomized Studies - of Interventions tool. Ethics and dissemination: This study does not require ethical approval. Findings will be submitted to an appropriate peer-reviewed journal. Trial registration number: CRD42021238879

Distress improves after mindfulness training for progressive MS: a pilot randomised trial

Background. Mindfulness-based interventions have been shown to effectively reduce anxiety, depression and pain in patients with chronic physical illnesses. Objectives. We assessed the potential effectiveness and cost-effectiveness of a specially adapted Skype distant-delivered mindfulness intervention, designed to reduce distress for people affected by primary and secondary progressive MS. Methods. Forty participants were randomly assigned to the 8-week intervention (n=19) or a waiting-list control group (n=21). Participants completed standardised questionnaires to measure mood, impact of MS and symptom severity, quality of life and service costs at baseline, post-intervention and 3-month follow-up. Results. Distress scores were lower in the intervention group compared with the control group at post-intervention and follow-up (p<0.05), effect size -.64 post-intervention and -.94 at follow-up. Mean scores for pain, fatigue, anxiety, depression, impact of MS were reduced for the mindfulness group compared with control group at post-therapy and follow-up; effect sizes ranging from -.27 to -.99 post-intervention and -.29 to -1.12 at follow-up. There were no differences in quality-adjusted life years, but an 87.4% probability that the intervention saves on service costs and improves outcome. Conclusions: A mindfulness intervention delivered through Skype video conferences appears accessible, feasible and potentially effective and cost-effective for people with progressive MS

The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study

Background: Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression. Methods: Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables. Result: 1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000. Conclusions: Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU

Mind the gap? The persistence of pathological discourses in urban regeneration policy

Urban regeneration policy has historically framed policy problems using a discourse that pathologises areas and spatial communities. Since 2001 in England, and 2002 in Scotland a structural change in policy has occurred where citywide partnerships are now meant overcome structural spatial inequalities, countering pathological explanations. This paper uses historical and discourse analysis to evaluate one of the major community regeneration strategies developed by the Scottish Executive in 2002: Better Communities in Scotland: Closing the Gap. It seeks to ask whether structural change in policy was paralleled by discursive change; what discursive path dependence is evidenced? The text is placed in the historic context of UK urban renewal policies dating back to the launch of the Urban Programme in 1968 and particularly the policy discourse created by the influential Conservative government policy of 1988 New Life for Urban Scotland and the wider discourses of poverty and neighbourhood renewal policy created by Labour governments since 1997. The close textual analysis of the text shows that Better Communities in Scotland continues to pathologise spatial communities. Although this suggests a degree of historical path dependency, the historic breadth of the analysis also problematises simple historical determinism

Magneto-transport study of intra- and intergrain transitions in the magnetic superconductors RuSr2GdCu2O8 and RuSr2(Gd1.5Ce0.5)Cu2O10

A characterization of the magnetic superconductors RuSr2GdCu2O8 [Ru-(1212)] and RuSr2(Gd1.5Ce0.5)Cu2O10 [Ru-(1222)] through resistance measurements as a function of temperature and magnetic field is presented. Two peaks in the derivative of the resistive curves are identified as intra- and intergrain superconducting transitions. Strong intragrain granularity effects are observed, and explained by considering the antiphase boundaries between structural domains of coherently rotated RuO6 octahedra as intragrain Josephson-junctions. A different field dependence of the intragrain transition temperature in these compounds was found. For Ru-(1212) it remains unchanged up to 0.1 T, decreasing for higher fields. In Ru-(1222) it smoothly diminishes with the increase in field even for a value as low as 100 Oe. These results are interpreted as a consequence of a spin-flop transition of the Ru moments. The large separation between the RuO2 layers in Ru-(1222) promotes a weak interlayer coupling, leading the magnetic transition to occur at lower fields. The suppression rate of the intragrain transition temperature is about five times higher for Ru-(1222), a result we relate to an enhancement of the 2D character of the vortex structure. A distinctive difference with conventional cuprates is the sharp increase in amplitude of the intergrain peak in both systems, as the field is raised, which is ascribed to percolation through a fraction of high quality intergrain junctions.Comment: Submitted for Physical Review

Unusual Field-Dependence of the Intragrain Superconductive Transition in RuSr2EuCu2O8

A narrow intragrain phase-lock transition was observed in RuSr2EuCu2O8 under a magnetic field H up to a few Tesla. The corresponding transition temperature, T2, decreases rapidly (about 100 K/T at low fields) with H indicating that the grains of RuSr2EuCu2O8 behave like a Josephson-junction-array instead of a homogeneous bulk superconductor. Our data suggest that the bulk superconducting transition may occur on a length scale well below the grain size of 2 to 6 micrometer

The emergence of 'citizenship' in popular discourse:The case of Scotland

The 2014 Scottish Referendum gauged public opinion on the possibility of Scotland leaving the United Kingdom, raising significant questions about the legitimacy of claims to citizenship in the event of independence. Through a mixed methods survey, this study explored the ways in which citizenship emerged in popular discourse in the lead up to the Scottish referendum. Findings point to an emphasis in public discourse on a commitment to and participation in society, instead of the more traditional citizenship markers of ancestry, birthplace or residency. Data indicates a view of citizenship encompassing status and practice, while identity was framed in terms of more static notions of birthplace and ancestry. The salience of social participation was noticeably greater in respondents’ assessment of others’ potential Scottish citizenship than their own. Specifically, the study highlights the salience of relational aspects of citizenship in popular discourse, with an emphasis on social citizenship in preference to legal citizenship. The study constitutes a significant contribution to ongoing discussions about ‘participatory citizenship’ in the field of Citizenship studies, by providing much needed empirical data on social conceptualizations of citizenship