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

Implications of the metallicity dependence of Wolf-Rayet winds

Aims: Recent theoretical predictions for the winds of Wolf-Rayet stars indicate that their mass-loss rates scale with the initial stellar metallicity in the local Universe.We aim to investigate how this predicted dependence affects the models of Wolf-Rayet stars and their progeny in different chemical environments. Methods: We compute models of stellar structure and evolution for Wolf-Rayet stars for different initial metallicities, and investigate how the scaling of the Wolf-Rayet mass-loss rates affects the final masses, the lifetimes of the WN and WC subtypes, and how the ratio of the two populations vary with metallicity. Results: We find significant effects of metallicity dependent mass-loss rates for Wolf-Rayet stars. For models that include the scaling of the mass-loss rate with initial metallicity, all WR stars become neutron stars rather than black holes at twice the solar metallicity; at lower $Z$, black holes have larger masses. We also show that our models that include the mass-loss metallicity scaling closely reproduce the observed decrease of the relative population of WC over WN stars at low metallicities.Comment: 8 pages, 9 figures, accepted by Astronomy & Astrophysic

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

Observations of the Optical Afterglow of GRB 050319 : Wind to ISM transition in view

The collapse of a massive star is believed to be the most probable progenitor of a long GRB. Such a star is expected to modify its environment by stellar wind. The effect of such a circum-stellar wind medium is expected to be seen in the evolution of a GRB afterglow, but has so far not been conclusively found. We claim that a signature of wind to constant density medium transition of circum-burst medium is visible in the afterglow of GRB 050319. Along with the optical observations of the afterglow of GRB 050319 we present a model for the multiband afterglow of GRB 050319. We show that the break seen in optical light curve at $\sim$ 0.02 day could be explained as being due to wind to constant density medium transition of circum-burst medium, in which case, to our knowledge, this could be the first ever detection of such a transition at any given frequency band. Detection of such a transition could also serve as a confirmation of massive star collapse scenario for GRB progenitors, independent of supernova signatures.Comment: 11 pages, 3 tables, 1 figure

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