Variation in compulsory psychiatric inpatient admission in England:a cross-sectional, multilevel analysis

Background: Rates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes. Objectives: To quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places. Design: Cross-sectional analysis using multilevel statistical modelling. Setting: England, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services. Participants: 1,287,730 patients. Main outcome measure: The study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period. Data sources: The Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers. Results: A total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models. Conclusions: This was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high. Funding: The National Institute for Health Research Health Services and Delivery Research programme

What are the current and projected future cost and health-related quality of life implications of scaling up cognitive stimulation therapy?

Objectives: Cognitive stimulation therapy (CST) is one of the few non-pharmacological interventions for people living with dementia shown to be effective and cost-effective. What are the current and future cost and health-related quality of life implications of scaling-up CST to eligible new cases of dementia in England? // Methods/design: Data from trials were combined with microsimulation and macrosimulation modelling to project future prevalence, needs and costs. Health and social costs, unpaid care costs and quality-adjusted life years (QALYs) were compared with and without scaling-up of CST and follow-on maintenance CST (MCST). // Results: Scaling-up group CST requires year-on-year increases in expenditure (mainly on staff), but these would be partially offset by reductions in health and care costs. Unpaid care costs would increase. Scaling-up MCST would also require additional expenditure, but without generating savings elsewhere. There would be improvements in general cognitive functioning and health-related quality of life, summarised in terms of QALY gains. Cost per QALY for CST alone would increase from £12,596 in 2015 to £19,573 by 2040, which is below the threshold for cost-effectiveness used by the National Institute for Health and Care Excellence (NICE). Cost per QALY for CST and MCST combined would grow from £19,883 in 2015 to £30,906 by 2040, making it less likely to be recommended by NICE on cost-effectiveness grounds. // Conclusions: Scaling-up CST England for people with incident dementia can improve lives in an affordable, cost-effective manner. Adding MCST also improves health-related quality of life, but the economic evidence is less compelling

Are genetic risk factors for psychosis also associated with dimension-specific psychotic experiences in adolescence?

Psychosis has been hypothesised to be a continuously distributed quantitative phenotype and disorders such as schizophrenia and bipolar disorder represent its extreme manifestations. Evidence suggests that common genetic variants play an important role in liability to both schizophrenia and bipolar disorder. Here we tested the hypothesis that these common variants would also influence psychotic experiences measured dimensionally in adolescents in the general population. Our aim was to test whether schizophrenia and bipolar disorder polygenic risk scores (PRS), as well as specific single nucleotide polymorphisms (SNPs) previously identified as risk variants for schizophrenia, were associated with adolescent dimension-specific psychotic experiences. Self-reported Paranoia, Hallucinations, Cognitive Disorganisation, Grandiosity, Anhedonia, and Parent-rated Negative Symptoms, as measured by the Specific Psychotic Experiences Questionnaire (SPEQ), were assessed in a community sample of 2,152 16-year-olds. Polygenic risk scores were calculated using estimates of the log of odds ratios from the Psychiatric Genomics Consortium GWAS stage-1 mega-analysis of schizophrenia and bipolar disorder. The polygenic risk analyses yielded no significant associations between schizophrenia and bipolar disorder PRS and the SPEQ measures. The analyses on the 28 individual SNPs previously associated with schizophrenia found that two SNPs in TCF4 returned a significant association with the SPEQ Paranoia dimension, rs17512836 (p-value=2.57x10-4) and rs9960767 (p-value=6.23x10-4). Replication in an independent sample of 16-year-olds (N=3,427) assessed using the Psychotic-Like Symptoms Questionnaire (PLIKS-Q), a composite measure of multiple positive psychotic experiences, failed to yield significant results. Future research with PRS derived from larger samples, as well as larger adolescent validation samples, would improve the predictive power to test these hypotheses further. The challenges of relating adult clinical diagnostic constructs such as schizophrenia to adolescent psychotic experiences at a genetic level are discussed

Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England

Background Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density – the so-called ‘ethnic density’ hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. Methods Data from the 2010–2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. Results Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95–0.99 and 0.94, 95% CI 0.93–0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11–1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. Conclusions We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act

Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression

OBJECTIVES: Face-to-face mindfulness interventions have been shown to significantly decrease perceived stress, anxiety and depression and research is beginning to show similar benefits for such courses delivered via the internet. We investigated the feasibility and effectiveness of an online mindfulness course for perceived stress, anxiety and depression. DESIGN: A follow-up investigation of an online mindfulness course. Previous research examining the change in perceived stress showed promising results. Measures of anxiety and depression were added to the online mindfulness course and these were investigated as well as perceived stress using a new, larger sample. PARTICIPANTS: Participants (N=273) were self-referrals to the online course who completed the outcome measure immediately before the course, upon course completion and at 1 month follow-up. INTERVENTION: The programme consists of 10 sessions, guided meditation videos and automated emails, with elements of Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy, completed at a pace to suit the individual (minimum length 4 weeks). PRIMARY AND SECONDARY OUTCOME MEASURES: The Perceived Stress Scale, the Generalised Anxiety Disorder Assessment-7 and the Patient Health Questionnaire-9 (for depression). Mindfulness practice was self-reported at automated time points upon login, once the exercises and sessions for each week were completed. RESULTS: Perceived stress, anxiety and depression significantly decreased at course completion and further decreased at 1 month follow-up, with effect sizes comparable to those found with face-to-face and other online mindfulness courses and to other types of intervention, such as cognitive behavioural therapy for stress. The amount of meditation practice reported did affect outcome when controlling for baseline severity. CONCLUSIONS: The online mindfulness course appears to be an acceptable, accessible intervention which reduces stress, anxiety and depression. However, there is no control comparison and future research is required to assess the effects of the course for different samples

Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression

OBJECTIVES: Face-to-face mindfulness interventions have been shown to significantly decrease perceived stress, anxiety and depression and research is beginning to show similar benefits for such courses delivered via the internet. We investigated the feasibility and effectiveness of an online mindfulness course for perceived stress, anxiety and depression. DESIGN: A follow-up investigation of an online mindfulness course. Previous research examining the change in perceived stress showed promising results. Measures of anxiety and depression were added to the online mindfulness course and these were investigated as well as perceived stress using a new, larger sample. PARTICIPANTS: Participants (N=273) were self-referrals to the online course who completed the outcome measure immediately before the course, upon course completion and at 1 month follow-up. INTERVENTION: The programme consists of 10 sessions, guided meditation videos and automated emails, with elements of Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy, completed at a pace to suit the individual (minimum length 4 weeks). PRIMARY AND SECONDARY OUTCOME MEASURES: The Perceived Stress Scale, the Generalised Anxiety Disorder Assessment-7 and the Patient Health Questionnaire-9 (for depression). Mindfulness practice was self-reported at automated time points upon login, once the exercises and sessions for each week were completed. RESULTS: Perceived stress, anxiety and depression significantly decreased at course completion and further decreased at 1 month follow-up, with effect sizes comparable to those found with face-to-face and other online mindfulness courses and to other types of intervention, such as cognitive behavioural therapy for stress. The amount of meditation practice reported did affect outcome when controlling for baseline severity. CONCLUSIONS: The online mindfulness course appears to be an acceptable, accessible intervention which reduces stress, anxiety and depression. However, there is no control comparison and future research is required to assess the effects of the course for different samples

The daytime impact of DSM-5 insomnia disorder: comparative analysis of insomnia subtypes from the Great British Sleep Survey.

OBJECTIVE: To profile the daytime impact of the proposed DSM-5 insomnia disorder diagnosis, with and without mental health, physical health, or other sleep disorder comorbidities; to better understand how specific daytime symptom patterns are associated with nighttime sleep in insomnia; and to compare childhood-onset and adulthood-onset insomnia disorder with respect to daytime dysfunction. METHOD: Data were derived from the Great British Sleep Survey (GBSS), an open-access online population survey completed by adults who had a valid postcode and were residents of the United Kingdom. The primary variables of interest were the 6 areas that, according to the proposed DSM-5 criteria, may be impacted in the daytime by insomnia disorder: energy, concentration, relationships, ability to stay awake, mood, and ability to get through work. These variables were compared for those with versus those without insomnia disorder and across 5 insomnia subtypes (difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, a combination of these 3 core symptoms, or nonrestorative sleep). Clinically comorbid insomnia presentations (insomnia disorder with poor mental health/poor physical health/additional sleep disorder symptoms) and insomnia disorder of childhood versus adult onset were also evaluated. RESULTS: A total of 11,129 participants (72% female; mean age = 39 years) completed the GBSS between March 2010 and April 2011, of whom 5,083 screened as having possible insomnia disorder. Compared with those who did not have insomnia disorder, those with insomnia disorder reported greater impairment in all areas of daytime functioning (Cohen d range, 0.68-1.30). The greatest effects reflected negative impact on energy and mood. Participants with a combination of insomnia symptoms tended to be the most impaired (Cohen d range, 0.10-0.23), whereas no consistent differences emerged between the other 4 subtypes. Finally, individuals who had both insomnia disorder and poor mental health were consistently the most impaired comorbid group (Cohen d range, 0.15-0.65), and childhood-onset insomnia disorder had greater daytime impact than adult-onset insomnia disorder (P < .05 for energy; P < .01 for mood, concentration, and getting through work). CONCLUSIONS: The severity of daytime impact of DSM-5 insomnia disorder varies by insomnia type. This finding has implications for the evaluation and management of insomnia in clinical practice

Niacin skin test response in dyslexia

The niacin skin test reflects a flush and oedema owing to the production of prostoglandin D2 from arachidonic acid. A diminished response may indicate abnormalities in the phospholipid metabolism, which has been shown in schizophrenia. There is evidence that dyslexia might also involved phospholipid abnormalities, therefore we examined the skin response in 51 dyslexics and 45 controls. Four concentrations of aqueous methyl nicotinate were applied topically to the forearm. Flushing was rated using a seven-point scale at 3 min intervals over 21 minutes. Repeated measures ANOVA for the four concentrations across all seven time-points showed no significant effect of subject group, but when analyses were confined to the first 9 min, flushing was reduced in dyslexics. Significant group differences were also found for the lowest niacin concentration (0.0001 M) across six out of seven time-points. The results indicate a slightly reduced and delayed response to niacin in dyslexics

Variation in Compulsory Psychiatric In-Patient Admission in England: A Cross-Sectional, Multilevel Analysis

contractual_start_date: 03-2012 editorial_review_begun: 09-2013 accepted_for_publication: 07-2014contractual_start_date: 03-2012 editorial_review_begun: 09-2013 accepted_for_publication: 07-2014contractual_start_date: 03-2012 editorial_review_begun: 09-2013 accepted_for_publication: 07-2014The National Institute for Health Research Health Services and Delivery Research programme