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A randomised controlled feasibility trial for an educational school-based mental health intervention: study protocol
Katharine Chisholm, Paul Patterson, Carole Torgerson, Erin Turner, Max Birchwood
BMC Psychiatry , 2012, DOI: 10.1186/1471-244x-12-23
Abstract: A cluster randomised controlled trial design has been employed to enable a feasibility study of 'SchoolSpace', an intervention in 7 UK secondary schools addressing stigma of mental illness, mental health literacy, and promotion of mental health. A central aspect of the intervention involves students in the experimental condition interacting with a young person with lived experience of mental illness, a stigma reducing technique designed to facilitate students' engagement in the project. The primary outcome is the level of stigma related to mental illness. Secondary outcomes include mental health literacy, resilience to mental illness, and emotional well-being. Outcomes will be measured pre and post intervention, as well as at 6 month follow-up.The proposed intervention presents the potential for increased engagement due to its combination of education and contact with a young person with lived experience of mental illness. Contact as a technique to reduce discrimination has been evaluated previously in research with adults, but has been employed in only a minority of research trials investigating the impact on youth. Prior to this study, the effect of contact on mental health literacy, resilience, and emotional well-being has not been evaluated to the authors' knowledge. If efficacious the intervention could provide a reliable and cost-effective method to reduce stigma in young people, whilst increasing mental health literacy, and emotional well-being.ISRCTN: ISRCTN07406026There is growing pressure on schools in England to address stigma and misconceptions of mental illness [2-5] as well as increasing emotional well-being [6,7] in addition to traditional academic curricula. Currently there is little agreement as to what approach might most successfully address these issues [9-11].Over half of all lifetime mental disorders have their onset during childhood and adolescence [12] yet young people's knowledge of mental illness is often incomplete [13] or influenced by se
Design of the BiRmingham Early Detection In untREated psyChosis Trial (REDIRECT): cluster randomised controlled trial of general practitioner education in detection of first episode psychosis [ISRCTN87898421]
Lynda Tait, Helen Lester, Max Birchwood, Nick Freemantle, Sue Wilson
BMC Health Services Research , 2005, DOI: 10.1186/1472-6963-5-19
Abstract: This paper describes the design of a stratified-cluster randomised controlled trial of an educational intervention on first episode psychosis in primary care. The primary outcome is the number of general practitioner referrals of young people with first episode psychosis to Early Intervention Services. Secondary outcomes are duration of untreated psychosis, time to recovery, use of the Mental Health Act, and general practitioner consultation rate. Young people with first episode psychosis referred to Early Intervention Services will be recruited over a two-year period from 1 March 2004. Seventy-eight out of 89 eligible general practices were recruited. The educational intervention has been implemented and evaluated by general practitioners. The education was well received and considered relevant to clinical practice by the general practitioners.The results suggest that the recruitment strategy and implementation of the educational intervention are feasible and acceptable in a primary care setting. The Redirect trial will provide robust information about the efficacy of an evidence-based complex educational intervention targeted at general practitioners on referral rates of young people with first episode psychosis to Early Intervention Services.Studies have shown that young people with first episode psychosis (FEP) experience lengthy delays between the onset of psychotic symptoms and receipt of treatment [1,2]. The average period from first onset of psychosis to initiation of adequate treatment (duration of untreated psychosis, or DUP) is one to two years [3]. During this untreated period, irreversible biological, social and psychological damage may take place [2], and a delay in treatment is associated with poorer short-term outcome and slower recovery [1]. Early intervention in this 'critical period' [4] is therefore important for both patients and families. Strategies to reduce DUP include providing early access to specialist mental health services, such as early
Don't turn your back on the symptoms of psychosis: a proof-of-principle, quasi-experimental public health trial to reduce the duration of untreated psychosis in Birmingham, UK
Charlotte Connor, Max Birchwood, Colin Palmer, Sunita Channa, Nick Freemantle, Helen Lester, Paul Patterson, Swaran Singh
BMC Psychiatry , 2013, DOI: 10.1186/1471-244x-13-67
Abstract: A quasi-experimental trial, comparing a targeted intervention area with a 'detection as usual' area in the same city. A proof-of--principle trial, no a priori assumptions are made regarding effect size; key outcome will be an estimate of the potential effect size for a definitive trial. DUP and number of new cases will be collected over an 18-month period in target and control areas and compared; historical data on DUP collected in both areas over the previous three years, will serve as a benchmark. The intervention will focus on reducing two significant DUP component delays within the overall care pathway: delays within the mental health service and help-seeking delay.This pragmatic trial will be the first to target known delays within the care pathway for those with a first episode of psychosis. If successful, this will provide a generalizable methodology that can be implemented in a variety of healthcare contexts with differing sources of delay.Trial registration: ISRCTN45058713
A multi-centre, randomised controlled trial of cognitive therapy to prevent harmful compliance with command hallucinations
Max Birchwood, Emmanuelle Peters, Nicholas Tarrier, Graham Dunn, Shon Lewis, Til Wykes, Linda Davies, Helen Lester, Maria Michail
BMC Psychiatry , 2011, DOI: 10.1186/1471-244x-11-155
Abstract: This is a single blind, intention-to-treat, multi-centre, randomized controlled trial comparing Cognitive Therapy for Command Hallucinations + Treatment as Usual with Treatment as Usual alone. Eligible participants have to fulfil the following inclusion criteria: i) ≥16 years; ii) ICD-10 diagnosis of schizophrenia or related disorder; iii) command hallucinations for at least 6 months leading to risk of harm to self or others. Following the completion of baseline assessments, eligible participants will be randomly allocated to either the Cognitive Therapy for Command Hallucinations + Treatment as Usual group or the Treatment as Usual group. Outcome will be assessed at 9 and 18 months post randomization with assessors blind to treatment allocation. The primary outcome is compliance behaviour and secondary outcomes include beliefs about voices' power, distress, psychotic symptoms together with a health economic evaluation. Qualitative interviews with services users will explore the acceptability of Cognitive Therapy for Command Hallucinations.Cognitive behaviour therapy is recommended for people with psychosis; however, its focus and evaluation has primarily revolved around the reduction of psychotic symptoms. In this trial, however, the focus of the cognitive behavioural intervention is on individuals' appraisals, behaviour and affect and not necessarily symptoms; this is also reflected in the outcome measures used. If successful, the results will mark a significant breakthrough in the evidence base for service users and clinicians and will provide a treatment option for this group where none currently exist. The trial will open the way for further breakthrough work with the 'high risk' population of individuals with psychosis, which we would intend to pursue.ISRCTN: ISRCTN62304114Schizophrenia affects 0.8% of the UK population, usually starts in early adult life and leads to persistent disability in most cases [1]. It carries a high risk of suicide (8%) and deliberat
A High-Fidelity Virtual Environment for the Study of Paranoia
Matthew R. Broome,Eva Zányi,Thomas Hamborg,Elmedin Selmanovic,Silvester Czanner,Max Birchwood,Alan Chalmers,Swaran P. Singh
Schizophrenia Research and Treatment , 2013, DOI: 10.1155/2013/538185
Abstract: Psychotic disorders carry social and economic costs for sufferers and society. Recent evidence highlights the risk posed by urban upbringing and social deprivation in the genesis of paranoia and psychosis. Evidence based psychological interventions are often not offered because of a lack of therapists. Virtual reality (VR) environments have been used to treat mental health problems. VR may be a way of understanding the aetiological processes in psychosis and increasing psychotherapeutic resources for its treatment. We developed a high-fidelity virtual reality scenario of an urban street scene to test the hypothesis that virtual urban exposure is able to generate paranoia to a comparable or greater extent than scenarios using indoor scenes. Participants ( ) entered the VR scenario for four minutes, after which time their degree of paranoid ideation was assessed. We demonstrated that the virtual reality scenario was able to elicit paranoia in a nonclinical, healthy group and that an urban scene was more likely to lead to higher levels of paranoia than a virtual indoor environment. We suggest that this study offers evidence to support the role of exposure to factors in the urban environment in the genesis and maintenance of psychotic experiences and symptoms. The realistic high-fidelity street scene scenario may offer a useful tool for therapists. 1. Introduction Psychosis, and psychotic disorders such as schizophrenia, is characterized by the presence of hallucinations (false perceptions) and delusions (false beliefs). It has become clear in recent years that the marked heterogeneity in the rates of schizophrenia and psychotic disorders across population groups [1] can be partly explained by urban birth and upbringing, migration, ethnicity, and what Cantor-Graae and Selten have termed “social defeat” [2, 3]. A particularly important recent body of research is the MRC AESOP study that demonstrated a twentyfold rate increase in the incidence of psychosis in London, compared with Nottingham and Bristol, and the very highest rates being within the Black and ethnic minority groups [4–8]. These epidemiological findings have strengthened continuum models of psychosis [9], which state that psychotic-like experiences are distributed in a normal nonclinical population and might be dependent upon many of the same variables as causally responsible for cases of the disorder [10]. Trying to connect psychological, biological, and social models of psychosis, and relating these to psychotic experiences and urbanicity in the general population, has become increasingly
CRIMSON [CRisis plan IMpact: Subjective and Objective coercion and eNgagement] Protocol: A randomised controlled trial of joint crisis plans to reduce compulsory treatment of people with psychosis
Graham Thornicroft, Simone Farrelly, Max Birchwood, Max Marshall, George Szmukler, Waquas Waheed, Sarah Byford, Graham Dunn, Claire Henderson, Helen Lester, Morven Leese, Diana Rose, Kim Sutherby
Trials , 2010, DOI: 10.1186/1745-6215-11-102
Abstract: This is a 3 centre, individual-level, single-blind, randomised controlled trial of the JCP compared with treatment as usual for people with a history of relapsing psychotic illness in Birmingham, London and Lancashire/Manchester. 540 service users will be recruited across the three sites. Eligible service users will be adults with a diagnosis of a psychotic disorder (including bipolar disorder), treated in the community under the Care Programme Approach with at least one admission to a psychiatric inpatient ward in the previous two years. Current inpatients and those subject to a community treatment order will be excluded to avoid any potential perceived pressure to participate. Research assessments will be conducted at baseline and 18 months. Following the baseline assessment, eligible service users will be randomly allocated to either develop a Joint Crisis Plan or continue with treatment as usual. Outcome will be assessed at 18 months with assessors blind to treatment allocation. The primary outcome is the proportion of service users treated or otherwise detained under an order of the Mental Health Act (MHA) during the follow-up period, compared across randomisation groups. Secondary outcomes include overall costs, service user engagement, perceived coercion and therapeutic relationships. Sub-analyses will explore the effectiveness of the JCP in reducing use of the MHA specifically for Black Caribbean and Black African service users (combined). Qualitative investigations with staff and service users will explore the acceptability of the JCPs.JCPs offer a potential solution to the rise of compulsory treatment for individuals with psychotic disorders and, if shown to be effective in this trial, they are likely to be of interest to mental health service providers worldwide.Current Controlled Trials ISRCTN11501328Two of the key guiding principles of mental health policy in England are that service users should: (i) exercise choice and control over their treatment [1]
Randomised Controlled Trial of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: Economic Outcomes
Barbara Barrett, Waquas Waheed, Simone Farrelly, Max Birchwood, Graham Dunn, Clare Flach, Claire Henderson, Morven Leese, Helen Lester, Max Marshall, Diana Rose, Kim Sutherby, George Szmukler, Graham Thornicroft, Sarah Byford
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0074210
Abstract: Background Compulsory admission to psychiatric hospitals may be distressing, disruptive to patients and families, and associated with considerable cost to the health service. Improved patient experience and cost reductions could be realised by providing cost-effective crisis planning services. Methods Economic evaluation within a multi-centre randomised controlled trial comparing Joint Crisis Plans (JCP) plus treatment as usual (TAU) to TAU alone for patients aged over 16, with at least one psychiatric hospital admission in the previous two years and on the Enhanced Care Programme Approach register. JCPs, containing the patient's treatment preferences for any future psychiatric emergency, are a form of crisis intervention that aim to mitigate the negative consequences of relapse, including hospital admission and use of coercion. Data were collected at baseline and 18-months after randomisation. The primary outcome was admission to hospital under the Mental Health Act. The economic evaluation took a service perspective (health, social care and criminal justice services) and a societal perspective (additionally including criminal activity and productivity losses). Findings The addition of JCPs to TAU had no significant effect on compulsory admissions or total societal cost per participant over 18-months follow-up. From the service cost perspective, however, evidence suggests a higher probability (80%) of JCPs being the more cost-effective option. Exploration by ethnic group highlights distinct patterns of costs and effects. Whilst the evidence does not support the cost-effectiveness of JCPs for White or Asian ethnic groups, there is at least a 90% probability of the JCP intervention being the more cost-effective option in the Black ethnic group. Interpretation The results by ethnic group are sufficiently striking to warrant further investigation into the potential for patient gain from JCPs among black patient groups. Trial Registration Current Controlled Trials ISRCTN11501328
The Modernisation of Manipulative Therapy  [PDF]
Max Zusman
International Journal of Clinical Medicine (IJCM) , 2011, DOI: 10.4236/ijcm.2011.25110
Abstract: Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative (currently “musculoskeletal”) therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “biomedical” model. This is further inexplicable in the light of evidence that not only the underlying “philosophy” but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant. The apparent inability of the profession to fully abandon outmoded “concepts” (and embrace the acknowledged science-based “best practice” biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.
On the Existence of Subharmonic Screech in Choked Circular Jets from a Sharp-Edged Orifice  [PDF]
Max Kandula
Open Journal of Acoustics (OJA) , 2014, DOI: 10.4236/oja.2014.41003
Abstract: Experiments are performed in choked circular hot and cold nitrogen jets issuing from a 2.44 cm diameter sharp-edged orifice at a fully expanded jet Mach number of 1.85 in an effort to investigate the character of screech phenomenon. The stagnation temperature of the cold and the hot jets are 299 K and 319 K respectively. The axial distribution of the centerline Mach number was obtained with a pitot tube, while the screech data (frequency and amplitude) at different axial and radial stations were measured with the aid of microphones. The fundamental screech frequency of the hot jet is slightly increased relative to that of the cold jet. It is concluded that temperature effects on the screech amplitude are manifested with regard to the fundamental and the subharmonic even at relatively small temperature range considered.
Management of neonatal hyperbilirubinemia: Pediatricians' practices and educational needs
Anna Petrova, Rajeev Mehta, Gillian Birchwood, Barbara Ostfeld, Thomas Hegyi
BMC Pediatrics , 2006, DOI: 10.1186/1471-2431-6-6
Abstract: A survey questionnaire was mailed to a random sample of 800 pediatricians selected from a list of 1623 New Jersey Fellows of the AAP initially in October 2003 and then in February 2004 for the non-respondents. In addition to the physicians' demographic characteristics, the questionnaire addressed various aspects of neonatal hyperbilirubinemia management including the diagnosis, treatment, and follow up as well as the pediatricians' beliefs regarding the significance of risk factors in the development of severe hyperbilirubinemia.The adjusted response rate of 49.1% (n = 356) was calculated from the 725 eligible respondents. Overall, the practicing pediatricians reported high utilization (77.9%) of the cephalocaudal progression of jaundice and low utilization (16.1%) of transcutaneous bilirubinometry for the quantification of the severity of jaundice. Most of the respondents (87.4%) identified jaundice as an indicator for serum bilirubin (TSB) testing prior to the neonate's discharge from hospital, whereas post-discharge, only 57.7% felt that a TSB was indicated (P < 0.01). If the neonate's age was under 72 hours, less than one-third of the respondents reported initiation of phototherapy at TSB levels lower than the treatment parameters recommended by the AAP in 1994, whereas if the infant was more than 72 hours old, almost 60% were initiating phototherapy at TSB lower than the 1994 AAP guidelines. Most respondents did not regard neonatal jaundice noted after discharge and gestational ages 37–38 weeks as being significant in the development of severe hyperbilirubinemia. However, the majority did recognize the importance of jaundice presenting within the first 24 hours and Rh/ABO incompatibility.The pediatricians' practices regarding the low utilization of laboratory diagnosis for the quantification of jaundice after discharge and underestimation of risk factors that contribute to the development of severe hyperbilirubinemia are associated with initiation of photothera
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