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Journal Article•DOI•

Day hospital versus admission for acute psychiatric disorders

Max Marshall1, Ruth Crowther2, William H. Sledge3, John Rathbone4, Karla Soares-Weiser •
University of Manchester1, University of Queensland2, Yale University3, University of Sheffield4
07 Dec 2011-Cochrane Database of Systematic Reviews (John Wiley & Sons, Ltd)-Vol. 2011, Iss: 12, pp 1-46
TL;DR: Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients, however, further data are still needed on the cost effectiveness of day hospitals.
Abstract: BACKGROUND: Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. OBJECTIVES: To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), PsycLIT (1966 to December 2000), and the reference lists of articles. We approached trialists to identify unpublished studies. SELECTION CRITERIA: Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. Individual patient data were therefore sought so that outcomes could be reanalysed in a common format. MAIN RESULTS: Nine trials (involving 1568 people) met the inclusion criteria. Individual patient data were obtained for four trials (involving 594 people). Combined data suggested that, at the most pessimistic estimate, day hospital treatment was feasible for 23% (n=2268, CI 21 to 25) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in number of days in hospital between day hospital patients and controls (n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55). However, compared to controls, people randomised to day hospital care spent significantly more days in day hospital care (n=265, 3 RCTs, WMD 2.34 days/month CI 1.97 to 2.70) and significantly fewer days in inpatient care (n=265, 3 RCTs, WMD -2.75 days/month CI -3.63 to -1.87). There was no significant difference in readmission rates between day hospital patients and controls (n=667, 5 RCTs, RR 0.91 CI 0.72 to 1.15). For patients judged suitable for day hospital care, individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n=407, Chi-squared 9.66, p=0.002), but not social functioning (n=295, Chi-squared 0.006, p=0.941) amongst patients treated in the day hospital. Four of five trials found that day hospital care was cheaper than inpatient care (with cost reductions ranging from 20.9 to 36.9%). REVIEWER'S CONCLUSIONS: Caring for people in acute day hospitals can achieve substantial reductions in the numbers of people needing inpatient care, whilst improving patient outcome.

Summary (2 min read)

Jump to: [Introduction] – [Nanotoxicology: a brief perspective] – [Nanotoxicology testing in vitro] and [Conclusion]

Introduction

  • Over the past twenty years, the increase in nanotoxicology research has been concomitant with the overwhelming increase in the level of nanotechnology-related products being produced (Maynard 2007).
  • Based on the principles of toxicology (Timbrell 1999), nanotoxicology can be defined as ‘the study of the effects The International Organization for Standardization (ISO), has provided specific definitions in their recent document entitled ‘‘Nanotechnologies – Terminology and definitions for nanoobjects—Nanoparticle, nanofibre and nanoplate’’.
  • It is well understood that the NP component contained within environmental air pollution, specifically particulate matter with a size of 10 lm or less (PM10), can increase the potential for humans to exhibit increased pulmonary diseases.
  • Due to the rapid advent of new, engineered NPs, as well as what is already known in regard to exposure to (accidentally produced).

Nanotoxicology: a brief perspective

  • Recently, the field of nanotoxicology has been described as a multi-interdisciplinary field, consisting of biologists (including toxicologists), chemists (including biochemists), physicists, mathematicians and epidemiologists (European Science Foundation (ESF) Report 2005).
  • Oberdorster et al. (1992) further suggested that the increased inflammatory response to acute NP exposure could not be explained fully by the movement of particles to the interstitium but could be related to the larger surface area of the particles and their interaction with alveolar macrophages and interstitial cells.
  • The findings of both Ferin et al. (1992) and Oberdorster et al. (1992) prompted increased interest into the effects of NPs on the lung, as well as the possible health effects that exposure to NPs might pose to respiratory and cardiovascular functions (Li et al. 1997, 1999) and why these effects are observed (Brown et al.
  • It is no longer sufficient to simply suspend a dry or wet sample of NPs in the suspension vehicle of choice and then expose the chosen model (i.e. tissue or cell cultures) to these NPs.
  • Due to the increased attention and funding opportunities provided for nanotoxicology research over the past 5–10 years, there has been an abundance of published studies claiming to be assessing the effects of NPs in relation to human health (Oberdorster et al. 2007).

Nanotoxicology testing in vitro

  • As highlighted earlier, the ability to perform such a magnitude of research, which is required in order to maintain an even balance of knowledge and understanding of the effects of NPs compared to the augmented production of NP-based products and applications, has been specifically due to the availability of in vitro testing strategies.
  • An example of such an effort is the triple cell co-culture system composed of epithelial cell line (A549 or 16HBE14o-), human monocyte-derived macrophages and dendritic cells that has been established, simulating the most important barrier functions of the epithelial airway by Rothen-Rutishauser et al. (2005).
  • Additionally, it is also necessary to determine the ability for the NPs used to interact with the assays in regard to the fluorescent dyes or formazans that are used.
  • If, however, a toxic response is observed following cellular exposure with NPs suspended in such buffers, it is essential that the toxicity of these buffers is known in order to assess the specific effects of the NPs only (Wick et al. 2007).

Conclusion

  • In summary, although the parameters highlighted in this review can be performed using either in vivo or in vitro models, due to the heightened level of control/baseline analysis needed, the advantages of in vitro research enable such experimental testing strategies beneficial to nanotoxicology.
  • This, however, will not be sufficiently covered by only performing monoculture analyses.
  • It is essential that co-culture systems mimicking the in vivo system are established and used for the specific organs that are in danger of interacting with NPs.
  • The authors would like to thank Christina Brandenberger, Andrea Lehmann, Loretta Mueller, Michael Gasser, David Raemy, Kirsten Dobson, Dagmar Kuhn, Andrea Stokes, Mohammed Ouanella and Barbara Tschirren for their vital input to the ongoing research of the laboratory of Prof.
  • The authors are entirely responsible for the content and writing of the manuscript.

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Figures (11)

Content maybe subject to copyright    Report

Cochrane Database of Systematic Reviews
Day hospital versus admission for acute psychiatric disorders
(Review)
Marshall M, Crowther R, Sledge WH, Rathbone J, Soares-Weiser K
Marshall M, Crowther R, Sledge WH, Rathbone J, Soares-Weiser K.
Day hospital versus admission for acute psychiatric disorders.
Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD004026.
DOI: 10.1002/14651858.CD004026.pub2.
www.cochranelibrary.com
Day hospital versus admission for acute psychiatric disorders (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
7BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
24DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 1 Feasibility and engagement:
lost to follow-up (at end of study). . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Analysis 1.2. Comparison 1 Day patient ver us inpatient care for Type 1 studies, Outcome 2 Extent of hospital care: 1a.
duration of index admission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.4. Comparison 1 Day patient verus inpatient care f or Type 1 studies, Outcome 4 Extent of hospital care: 2.
duration of all hospital care (days/month). . . . . . . . . . . . . . . . . . . . . . . . . 61
Analysis 1.5. Comparison 1 Day patient verus inpatient care f or Type 1 studies, Outcome 5 Extent of hospital care: 3.
duration of day patient care (adjusted days/month). . . . . . . . . . . . . . . . . . . . . . 61
Analysis 1.6. Comparison 1 Day patient verus inpatient care f or Type 1 studies, Outcome 6 Extent of hospital care: 4.
duration of stay in hospital (days/month). . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 1.7. Comparison 1 Day patient verus inpatient care f or Type 1 studies, Outcome 7 Extent of hospital care: 5.
readmitted to in/day patient care after discharge. . . . . . . . . . . . . . . . . . . . . . . 63
Analysis 1.8. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 8 Mental state: average endpoint
score (BPRS, high = poor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.9. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 9 Social functioning: average
overall role score (GSDS-II, high = poor). . . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 1.10. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 10 Burden: average carers’ score
(SBAS, high = poor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Analysis 1.11. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 11 Death (all causes). . 67
Analysis 1.12. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 12 Unemployed (at end of
study). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 1.13. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 13 Satisfaction with care: 1. not
satisfied with care received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 1.14. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 14 Satisfaction with care: 2.
average overall score (CAT, low = poor). . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis 1.17. Comparison 1 Day patient verus inpatient care for Type 1 studies, Outcome 17 Quality of life: average
overall role score (MANSA, low = poor). . . . . . . . . . . . . . . . . . . . . . . . . 70
Analysis 2.1. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 1 Feasibility and engagement: lost to follow-up (at 2 years). . . . . . . . . . . 71
Analysis 2.2. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 2 Extent of hospital care: 1. duration of all hospital care (days/month, IPD - “nights in” &
“nights out”). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Analysis 2.3. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 3 Extent of hospital care: 2. readmitted to in/day patient care after discharge. . . . 72
iDay hospital versus admission for acute psychiatric disorders (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.4. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 4 Mental state: average endpoint score (PSE 9, high = poor, IPD). . . . . . . . 73
Analysis 2.5. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 5 Social functioning: average overall role score (Groningen Scale, IPD). . . . . . 74
Analysis 2.6. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 6 Death (all causes). . . . . . . . . . . . . . . . . . . . . . . . 75
Analysis 2.7. Comparison 2 Day patient versus inpatient care for Type 2 trials (all presenting for admission were
randomised), Outcome 7 Unemployed (at e nd of study). . . . . . . . . . . . . . . . . . . . 76
76ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81WHAT’ S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82DIFFERENCES BETWEEN PROTOCOL AN D REVIEW . . . . . . . . . . . . . . . . . . . . .
82INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiDay hospital versus admissi on for acute psychiatric disorders (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Day hospital versus admission for acute psychiatric disorders
Max Marshall
1
, Ruth Crowther
2
, William Hurt Sledge
3
, John Rathbone
4
, Karla Soares-Weiser
5
1
University of Manchester, The Lantern Centre, Preston., UK.
2
School of Population Health, University of Queensland, Queensland,
Australia.
3
Yale New Haven Psychiatric Hospital, Yale University, Hamden, Connecticutt, USA.
4
HEDS, ScHARR, The University of
Sheffield, Sheffield, UK.
5
Enhance Reviews Ltd, Wantage, UK
Contact address: Max Marshall, University of Manchester, The Lantern Centre, Vicarage Lane, Of Watling Street Road, Fulwood,
Preston., Lancashire, UK.
max.marshall@manchester.ac.uk. max.marshall@lancashirecare.nhs.uk.
Editorial group: Cochrane Schizophrenia Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 12, 2011.
Review content assessed as up-to-date: 17 February 2011.
Citation: Marshall M, Crowther R, Sledge WH, Rathbone J, Soares-Weiser K. Day hospital versus admission for acute psychiatric
disorders. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD004026. DOI: 10.1002/14651858.CD004026.pub2.
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those
currently treated as inpatients could be cared for in acute psychiatric day hospitals.
Objectives
To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders.
Search methods
We searched the Cochrane Schizophrenia Group Trials Register (June 2010) which is based on regular searches of MEDLINE, EMBASE,
CINAHL and PsycINFO. We approached trialists to identify unpublished studies.
Selection criteria
Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible
if a majority of participants were under 18 or over 65, or had a pr imary diagnosis of substance abuse or organic brain disorder.
Data collection and analysis
Two review authors independently extracted and cross-checked data. We cal cul ated risk ratios (RR) and 95% confidence intervals (CI)
for dichotomous data. We calculated weighted or standardised means for continuous data. Day hospital trials tend to present similar
outcomes in slightl y different formats, making it difficult to synthesise data. We therefore sought individual patient data so that we
could re-analyse outcomes in a common format.
Main results
Ten trials (involving 2685 pe ople) met the inclusion criteria. We obtained individual patient data for four trials (involving 646 people).
We found no difference in the number lost to follow-up by one year between day hospital care and inpatient care (5 RCTs, n = 1694,
RR 0.94 CI 0.82 to 1.08). There is moderate evidence that the duration of index admission is longer for patients in day hospital care
than inpatient care (4 RCTs, n = 1582, WMD 27.47 CI 3.96 to 50.98). There is very low evidence that the duration of day patient
care (adjusted days/month) is l onger for patients in day hospital care than inpatient care (3 RCTs, n = 265, WMD 2.34 days/month CI
1.97 to 2.70). There is no difference between day hospital care and inpatient care for the being readmitted to in/day patient care after
1Day hospital versus admission for acute psychiatric disorders (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
discharge (5 RCTs, n = 667, RR 0.91 CI 0.72 to 1.15). It is likely that there is no difference between day hospital care and inpatient
care for being unemployed at the end of the study (1 RCT, n = 179, RR 0.88 CI 0.66 to 1.19), for quality of life (1 RCT, n = 1117,
MD 0.01 CI -0.13 to 0.15) or f or treatment satisfaction (1 RCT, n = 1117, MD 0.06 CI -0.18 to 0.30).
Authors’ conclusions
Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients. However, further data
are still neede d on th e cost effectiveness of day hospitals.
P L A I N L A N G U A G E S U M M A R Y
Day hospital versus admission for acute psychiatric disorders
Day hospitals are a less restrictive alternative to inpatient admission for people who are acutely and severely mentally il l. This review
compares acute day hospital care to inpatient care. We found that at least one in five patients currently admitted to inpatient care could
feasibly be cared for in an acute day hospital. Patients treated in the day hospital had the same levels of treatment satisfaction and quality
of life as those cared for as inpatients. The day hospital patients were also no more likely to be unemployed at the end of their care.
2Day hospital versus admission for acute psychiatric disorders (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Citations
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Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial

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Beate Herpertz-Dahlmann1, Reinhild Schwarte1, Melanie Krei1, Karin Egberts, Andreas Warnke, Christoph Wewetzer, Ernst Pfeiffer2, Christian Fleischhaker, André Scherag3, Kristian Holtkamp, Ulrich Hagenah1, Katharina Bühren1, Kerstin Konrad1, Ulrike Schmidt4, Carmen Schade-Brittinger5, Nina Timmesfeld5, Astrid Dempfle5 •
RWTH Aachen University1, Charité2, University of Duisburg-Essen3, King's College London4, University of Marburg5
05 Apr 2014-The Lancet
TL;DR: DP after short inpatient care in adolescent patients with non-chronic anorexia nervosa seems no less effective than IP for weight restoration and maintenance during the first year after admission, and might be a safe and less costly alternative to IP.

205 citations

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The balanced care model for global mental health.

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Graham Thornicroft1, Michele Tansella2•
King's College London1, University of Verona2
01 Apr 2013-Psychological Medicine
TL;DR: The balanced care model (BCM) indicates that a comprehensive mental health system includes both community- and hospital-based components of care, whether this is in low-, medium- or high-resource settings.
Abstract: Background For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings. Results Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop ‘general adult mental health services’, namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories. Conclusions The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

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Complex interventions and their implications for systematic reviews: A pragmatic approach

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Mark Petticrew1, Laurie M. Anderson2, Randy W. Elder3, Jeremy M. Grimshaw4, David S. P. Hopkins3, Robert A. Hahn3, Lauren Krause5, Elizabeth Kristjansson4, Shawna L. Mercer3, Teresa Sipe3, Peter Tugwell4, Erin Ueffing6, Elizabeth Waters7, Vivian Welch4 •
University of London1, Washington State Institute for Public Policy2, Centers for Disease Control and Prevention3, University of Ottawa4, Colorado School of Public Health5, Ottawa Hospital Research Institute6, University of Melbourne7
01 Nov 2013-Journal of Clinical Epidemiology
TL;DR: It is argued that reviews of complex interventions can themselves be simple or complex, depending on the question to be answered, and should follow the principle of Occam's razor: explanations should be as complex as they need to be and no more.

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General psychiatric services for adults with intellectual disability and mental illness

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R Chaplin
01 Jan 2004-Journal of Intellectual Disability Research
TL;DR: There is no conclusive evidence to favour the use of general or specialist psychiatric services for people with intellectual disability and mental illness and further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred.
Abstract: Background Adults with intellectual disability (ID) and mental illness may use general or specialist psychiatric services. This review aims to assess if there is evidence for a difference in outcome between them. Methods A literature review was conducted using a variety of electronic databases and hand-search strategies to identify all studies evaluating the outcome of people with ID and mental illness using general psychiatric services. Results There is no conclusive evidence to favour the use of general or specialist psychiatric services. People with ID stay less time on general psychiatric than specialist inpatient units. People with severe ID appear not to be well served in general services. Older studies of inpatient samples suggest a worse outcome for people with ID. Novel specialist services generally improve upon pre-existing general services. Assertive outreach in general services may preferentially benefit those with ID. Recent studies suggest similar lengths of stay in general psychiatric beds for people with and without ID. Conclusions Although 27 studies were located, only two were randomized controlled trials. The evidence is poor quality therefore further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred.

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Lessons learned in developing community mental health care in Europe.

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Maya Semrau1, Elizabeth Barley1, Ann Law1, Graham Thornicroft1•
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13 Sep 1997-BMJ
TL;DR: Funnel plots, plots of the trials' effect estimates against sample size, are skewed and asymmetrical in the presence of publication bias and other biases Funnel plot asymmetry, measured by regression analysis, predicts discordance of results when meta-analyses are compared with single large trials.
Abstract: Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews . Main outcome measure: Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision. Results: In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias. Conclusions: A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution. Key messages Systematic reviews of randomised trials are the best strategy for appraising evidence; however, the findings of some meta-analyses were later contradicted by large trials Funnel plots, plots of the trials9 effect estimates against sample size, are skewed and asymmetrical in the presence of publication bias and other biases Funnel plot asymmetry, measured by regression analysis, predicts discordance of results when meta-analyses are compared with single large trials Funnel plot asymmetry was found in 38% of meta-analyses published in leading general medicine journals and in 13% of reviews from the Cochrane Database of Systematic Reviews Critical examination of systematic reviews for publication and related biases should be considered a routine procedure

37,989 citations

Journal Article•DOI•
Pharmacological interventions for somatoform disorders in adults.

[...]

Maria Kleinstäuber1, Michael Witthöft2, Andrés Steffanowski3, Harm W.J. van Marwijk4, Wolfgang Hiller2, Michael J. Lambert5 •
University of Marburg1, University of Mainz2, University of Mannheim3, VU University Medical Center4, Brigham Young University5
07 Nov 2014-Cochrane Database of Systematic Reviews
TL;DR: A systematic review and meta-analysis of placebo-controlled studies examined the efficacy and tolerability of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products in adults with somatoform disorders in adults to improve optimal treatment decisions.
Abstract: BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

11,458 citations

Journal Article•DOI•
The Brief Psychiatric Rating Scale

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John E. Overall1, Donald R. Gorham•
Kansas State University1
01 Jun 1962-Psychological Reports
TL;DR: The Brief Psychiatric Rating Scale (BRS) as mentioned in this paper was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change, and it is recommended for use where efficiency, speed, and economy are important considerations.
Abstract: The Brief Psychiatric Rating Scale was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change. Sixteen symptom constructs which have resulted from factor analyses of several larger sets of items, principally Lorr's Multidimensional Scale for Rating Psychiatric Patients (MSRPP) (1953) and Inpatient Multidimensional Psychiatric Scale (IMPS) (1960), have been included for rating on 7-point ordered category rating scales. The attempt has been to include a single scale to record degree of symptomacology in each of the relatively independent symptom areas which have been identified. Some of the preliminary work which has led to the identification of primary symptom constructs has been published (Gorham & Overall, 1960, 1961, Overall, Gorharn, & Shawver, 1961). While other reports are in preparation, applications of the Brief Scale in both pure and applied research suggest the importance of presenting the basic instrument to the wider scientific audience at this time, together with recommendations for its standard use. The primary purpose in developing the Brief Scale has been the development of a highly efficient, rapid evaluation procedure for use in assessing treatment change in psychiatric patients while at the same time yielding a rather comprehensive description of major symptom characteristics. It is recommended for use where efficiency, speed, and economy are important considerations, while more detailed evaluation procedures, such as those developed by Lorr (1953, 1961) should perhaps be wed in other cases. In order to achieve the maximum effectiveness in use of the Brief Scale, a standard interview procedure and more detailed description of rating concepts are included in this report. In addition, each symptom concept is defined briefly in the rating scale statements themselves. Raters using the scale should become thoroughly familiar with the scale definitions presented herein, after which the rating scale statements should be sufficient to provide recall of the nature and delineation of each symptom area. , To increase the reliability of ratings, it is recommended that patients be interviewed jointly by a team of two clinicians, with the two raters making independent ratings at the completion of the interview. An alternative procedure which has been recommended by some is to have raters discuss and arrive at a

10,457 citations

Journal Article•DOI•
Interventions for latent autoimmune diabetes (LADA) in adults.

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Sinead Brophy1, Helen Davies1, Sopna Mannan1, Huw Brunt, Rhys Williams1 •
Swansea University1
07 Sep 2011-Cochrane Database of Systematic Reviews
TL;DR: Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin.
Abstract: Background Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. Objectives To compare interventions used for LADA. Search methods Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. Selection criteria Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. Data collection and analysis Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta-analysis or descriptive methods. Main results Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow-up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: -1.3% (95% confidence interval (CI) -2.4 to -0.1; P = 0.03, 160 participants, four studies, follow-up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow-up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C-peptide levels (20 μg group) were maintained after five years. Short term (three months) follow-up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C-peptide levels compared to insulin alone (0.07 µg/L (95% CI -0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C-peptide levels in the vitamin D group but declining fasting C-peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow-up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health-related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). Authors' conclusions Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C-peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA.

6,882 citations

Related Papers (5)
Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care.

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01 Jan 2001-Health Technology Assessment
Max Marshall, Ruth Crowther, Almaraz-Serrano Am, FH Creed, William H. Sledge, H. Kluiter, Chris Roberts, E. Hill, D. Wiersma, Gary R. Bond, Peter Huxley, Peter Tyrer 
Crisis Intervention for People With Severe Mental Illnesses

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13 Apr 2011-Cochrane Database of Systematic Reviews
Max Marshall, Austin Lockwood
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18 Jul 2007-Cochrane Database of Systematic Reviews
Darren Malone, Sarah Marriott, Giles Newton-Howes, Shaeda Simmonds, Peter Tyrer 
Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence.

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01 Oct 2004-British Journal of Psychiatry
Graham Thornicroft, Michele Tansella
Frequently Asked Questions (7)
Q1. What contributions have the authors mentioned in the paper "Cochrane database of systematic reviews day hospital versus admission for acute psychiatric disorders (review)" ?

In this paper, the authors compared acute day hospital care to inpatient care for acute psychiatric disorders and found that patients treated in the day hospital had the same levels of treatment satisfaction and quality of life as those cared for as inpatients. 

GRADE Working Group grades of evidence High quality: further research is very unlikely to change their confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on their confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on their confidence in the estimate of effect and is likely to change the estimate. Despite these problems, remorseless pressure on inpatient facilities has led to continued interest in psychiatric day hospitals and has inspired the development of newstyle day hospitals augmented by outreach services, crisis beds, and extended hours programmes ( Creed-UK-1996 ; Schene 1988 ; Sledge-US-1996 ). 

The authors found that at least one in five patients currently admitted to inpatient care could feasibly be cared for in an acute day hospital. 

People with acute psychiatric disorders, diagnosed by any criteria, who would have been admitted to inpatient care if acute day hospital care had not been available. 

Of 5 relevant RCTs, 2 had inadequate sequence generation, 3 had inadequate allocation concealment, none addressed incomplete data adequately and it was unclear whether any were free from other biases. 

Risk of bias: rated ’very serious’/of 3 relevant RCTs, 1 - inadequate sequence generation and allocation concealment, none addressed incomplete data adequately. 

The mean extent of hospital care: 3. duration of day patient care (adjusted days/month) in the intervention groups was 2.34 higher (1.97 to 2.7 higher)465 (3 studies)⊕©©© very low4,5Extent of hospital care: 5. readmitted to in/day patient care after discharge Follow-up: 10 to 24 monthsLow1 RR 0.91(0.72 to 1.15)667 (5 studies)⊕©©© very low6,7100 per 1000 91 per 1000(72 to 115)Moderate1300 per 1000 273 per 1000(216 to 345)High1500 per 1000 455 per 1000(360 to 575)Unemployed (at end of study) Follow-up: 2 to 12 monthsLow1 RR 0.81(0.67 to 0.97)320 (2 studies)⊕⊕©© low8,9200 per 1000 162 per 1000(134 to 194)Moderate1600 per 1000 486 per 1000(402 to 582)High1900 per 1000 729 per 1000(603 to 873) 4 D a y h o sp ita l v e rsu s a d m issio n fo r a c u te p sy c h ia tric d iso rd e rs (R e v ie w ) C o p y rig h t © 2 0 1 1 T h e C o c h ra n e C o lla b o ra tio n .