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

On the nature of the progenitors of three type II-P supernovae: 2004et, 2006my and 2006ov

The pre-explosion observations of the type II-P supernovae 2006my, 2006ov and 2004et, are re-analysed. In the cases of supernovae 2006my and 2006ov we argue that the published candidate progenitors are not coincident with their respective supernova sites in pre-explosion Hubble Space Telescope observations. We therefore derive upper luminosity and mass limits for the unseen progenitors of both these supernovae, assuming they are red supergiants: 2006my (log L/Lsun = 4.51; mass < 13Msun) and 2006ov (log L/Lsun = 4.29; mass < 10Msun). In the case of supernova 2004et we show that the yellow-supergiant progenitor candidate, originally identified in Canada France Hawaii Telescope images, is still visible ~3 years post-explosion in observations from the William Herschel Telescope. High-resolution Hubble Space Telescope and Gemini (North) adaptive optics late-time imagery reveal that this source is not a single yellow supergiant star, but rather is resolved into at least three distinct sources. We report the discovery of the unresolved progenitor as an excess of flux in pre-explosion Isaac Newton Telescope i'-band imaging. Accounting for the late-time contribution of the supernova using published optical spectra, we calculate the progenitor photometry as the difference between the pre- and post-explosion, ground-based observations. We find the progenitor was most likely a late K to late M-type supergiant of 8 +5/-1 Msun. In all cases we conclude that future, high-resolution observations of the supernova sites will be required to confirm these results.Comment: 43 pages (pre-print format), 12 figures, 10 tables. Significant revision following referee's comments. Accepted for publication in MNRA

Binary Population and Spectral Synthesis Version 2.1: construction, observational verification and new results

The Binary Population and Spectral Synthesis (BPASS) suite of binary stellar evolution models and synthetic stellar populations provides a framework for the physically motivated analysis of both the integrated light from distant stellar populations and the detailed properties of those nearby. We present a new version 2.1 data release of these models, detailing the methodology by which BPASS incorporates binary mass transfer and its effect on stellar evolution pathways, as well as the construction of simple stellar populations. We demonstrate key tests of the latest BPASS model suite demonstrating its ability to reproduce the colours and derived properties of resolved stellar populations, including well- constrained eclipsing binaries. We consider observational constraints on the ratio of massive star types and the distribution of stellar remnant masses. We describe the identification of supernova progenitors in our models, and demonstrate a good agreement to the properties of observed progenitors. We also test our models against photometric and spectroscopic observations of unresolved stellar populations, both in the local and distant Universe, finding that binary models provide a self-consistent explanation for observed galaxy properties across a broad redshift range. Finally, we carefully describe the limitations of our models, and areas where we expect to see significant improvement in future versions.Comment: 69 pages, 45 figures. Accepted for publication in PASA. Accompanied by a full, documented data release at http://bpass.auckland.ac.nz and http://warwick.ac.uk/bpas

A deeper search for the progenitor of the Type Ic Supernova 2002ap

(Abridged) We present a search for the progenitor star of the Type Ic Supernova 2002ap in deep, high quality pre-explosion observations taken with the Canada-France-Hawaii Telescope (CFHT). Aligning high-resolution Hubble Space Telescope (HST) observations of the supernova itself with the archival CFHT images allowed us to pinpoint the location of the progenitor site on the ground based observations. We find that a source visible in the B and R band pre-explosion images close to the position of the SN is (1) not coincident with the SN position within the uncertainties of our relative astrometry, and (2) is still visible ~ 4.7 yrs post-explosion in late-time observations taken with the William Herschel Telescope. We therefore conclude that it is not the progenitor of SN 2002ap. Comparing our luminosity limits with stellar models of single stars at appropriate metallicity (Z=0.008) we conclude that any single star progenitor must have experienced at least twice the standard mass loss rates during pre-Wolf-Rayet evolution, been initially > 30-40M(Sun) and exploded as a Wolf-Rayet star of final mass 10-12M(Sun). Alternatively an initially less massive progenitor may have evolved in an interacting binary system. We constrain any possible binary companion to a main sequence star of < 20M(Sun), a neutron star or a black hole. By combining the pre-explosion limits with the ejecta mass estimates and constraints from X-ray and radio observations we conclude that any binary interaction most likely occurred as Case B mass transfer, either with or without a subsequent common envelope evolution phase.Comment: 20 pages, 11 figures (resolution of images reduced), 6 tables. Accepted for publication in MNRAS 2007 July 27 (received 2007 July 23; in original form 2007 June 04

The type IIb SN 2008ax: the nature of the progenitor

A source coincident with the position of the type IIb supernova (SN) 2008ax is identified in pre-explosion Hubble Space Telescope (HST) Wide Field Planetary Camera 2 observations in three optical filters. We identify and constrain two possible progenitor systems: (i) a single massive star that lost most of its hydrogen envelope through radiatively driven mass loss processes, prior to exploding as a helium-rich Wolf-Rayet star with a residual hydrogen envelope, and (ii) an interacting binary in a low mass cluster producing a stripped progenitor. Late time, high resolution observations along with detailed modelling of the SN will be required to reveal the true nature of this progenitor star.Comment: 5 pages, 2 figures, resolution of figure 1 reduced, figure 2 revised, some revision following referee's comments, accepted for publication in MNRAS letter

Absence of the Rashba effect in undoped asymmetric quantum wells

To an electron moving in free space an electric field appears as a magnetic field which interacts with and can reorient the electron spin. In semiconductor quantum wells this spin-orbit interaction seems to offer the possibility of gate-voltage control in spintronic devices but, as the electrons are subject to both ion-core and macroscopic structural potentials, this over-simple picture has lead to intense debate. For example, an externally applied field acting on the envelope of the electron wavefunction determined by the macroscopic potential, underestimates the experimentally observed spin-orbit field by many orders of magnitude while the Ehrenfest theorem suggests that it should actually be zero. Here we challenge, both experimentally and theoretically, the widely held belief that any inversion asymmetry of the macroscopic potential, not only electric field, will produce a significant spin-orbit field for electrons. This conclusion has far-reaching consequences for the design of spintronic devices while illuminating important fundamental physics.Comment: 7 pages, 5 fig

New constraints on the Bray conservation-of-momentum natal kick model from multiple distinct observations

Natal supernova kicks, the linear momentum compact remnants receive during their formation, are an essential part of binary population synthesis (BPS) models. Although these kicks are well-supported by evidence, their underlying distributions and incorporation into BPS models is uncertain. In this work, we investigate the nature of natal kicks using a previously proposed analytical prescription where the strength of the kick is linearly proportional to the ejecta-remnant mass ratio. We vary the free parameters over large ranges of possible values, comparing these synthetic populations simultaneously against four constraints: the merger rate of compact binary neutron star (BNS) systems, the period-eccentricity distribution of galactic BNSs, the velocity distribution of single-star pulsars, and the likelihood for low-ejecta mass supernovae to produce low-velocity kicks. We find that different samples of the parameter space satisfy each tests, and only 1 per cent of the models satisfy all four constraints simultaneously. Although we cannot identify a single best kick model, we report $\alpha = 80 \pm 30$ km s$^{-1}$, $\beta = 0 \pm 20$ km s$^{-1}$ as the center of the region of the parameter space that fulfils all of our constraints, and expect $\beta \geq 0$ km s$^{-1}$ as a further constraint. We also suggest further observations that will enable future refinement of the kick model. A sensitive test for the kick model will be the redshift evolution of the BNS merger rate since this is effectively a direct measure of the delay-time distribution for mergers. For our best fitting values, we find that the peak of the BNS merger rate is the present-day.Comment: Submitted to MNRA