Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia. Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered. Results: Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at A$160 000/DALY. Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Attitude change and the public-private attitude distinction

In this paper, we highlight the importance of the distinction between public and private attitudes in research on attitude change. First, we clarify the definitions of public and private attitudes by locating the researcher as a potential source of influence. In a test of this definition, we compare participant reports of potentially embarrassing behaviour and the study's importance between participants responding when a researcher has potential access to their reports (public condition), and participants whose reports the researcher has no potential access to (private condition). Participants high in public self-focus or low in defensive self-presentation reported the study to be more important in the public condition than the private condition. Further, participants in the public condition reported less frequency of engaging in embarrassing behaviours than those in the private condition, an effect not moderated by individual differences. We conclude that the public-private distinction is an essential element in attitude change theory.

Looking beyond the negatives: A time period analysis of positive cognitions, negative cognitions, and working alliance in cognitive-behavior therapy for panic disorder

Time period analysis was used in an international sample of clients ( N = 106) to demonstrate that cognitive - behavioral therapy (CBT) for panic disorder is associated with specific changes in both negative and positive cognitions during the treatment period. In the first 6 weeks of the treatment phase, working alliance failed to predict changes in panic severity, whereas changes in panic self-efficacy and catastrophic misinterpretation of bodily sensations predicted rapid symptom relief. In the last 6 weeks of treatment, higher doses of CBT were associated with further changes in positive and negative cognitions. The findings can be interpreted as suggesting that the role of the working alliance in CBT for panic disorder is to facilitate cognitive change.

Cognitive change process during group cognitive behaviour therapy for depression

Background: This study extended that of Kwon and Oei [Kwon, S.M., Oei, T.P.S., 2003. Cognitive change processes in a group cognitive behavior therapy of depression. J. Behav. Ther. Exp. Psychiatry, 3, 73-85], which outlined a number of testable models based on Beck's cognitive theory of depression. Specifically, the current study tested the following four competing models: the causal, consequential, fully and partially interactive cognitive models in patients with major depressive disorder. Methods: A total of 168 clinically depressed outpatients were recruited into a 12-week group cognitive behaviour therapy program. Data was collected at three time points: baseline, mid- and at termination of therapy using the ATQ DAS and BD1. The data were analysed with Amos 4.01 (Arbuckle, J.L., 1999. Amos 4.1. Smallwaters, Chicago.) structural equation modelling. Results: Results indicated that dysfunctional attitudes, negative automatic thoughts and symptoms of depression reduced significantly during treatment. Both the causal and consequential models equally provided an adequate fit to the data. The fully interactive model provided the best fit. However, after removing non-significant pathways, it was found that reduced depressive symptom contributed to reduced depressogenic automatic thoughts and dysfunctional attitudes, not the reverse. Conclusion: These findings did not fully support Beck's cognitive theory of depression that cognitions are primary in the reduction of depressed mood. (c) 2006 Elsevier B.V. All rights reserved.

Interfacial behavior of tetrapyridylporphyrin monolayer arrays

The behavior of monolayer films of free base 5,10,15,20-tetrapyridylporphinato (TPyP) and 5,10,15,20-tetrapyridylporphinato zinc(II) (ZnTPyP) on pure water, 0.1 M CdCl2, and 0.1 M CuCl2 subphases was investigated by surface pressure-area isotherms, specular X-ray reflectometry, and polarized total reflection X-ray absorption spectroscopy (PTRXAS). Surface pressure-area isotherms showed significant differences in the area per molecule on pure water compared to that on salt subphases, with a marked increase in the area observed on the salt solutions. This behavior was noted for both forms of the porphyrin and both salts investigated. Modeling of specular X-ray reflectometry data indicated that thinner and more electron dense layers on salt subphases best fit the observed profiles. These data suggest that the porphyrin macrocycle is oriented parallel to the interface on salt subphases and takes on a tilted conformation on pure water. In the case of ZnTPyP, PTRXAS was used to determine the orientation of the porphyrin moiety relative to the surface and to probe the coordination of the central Zn ion. In agreement with the pressure-area isotherms and reflectometry, the PTRXAS data indicate a change in orientation on the salt subphases.

Social cognitive predictors of sun protection intention and behavior

The authors investigated sunbathing behavior and intention prospectively using the Theory of Planned Behavior (TPB). Before summer, 85 young adults who intended to sunbathe completed a TPB questionnaire. After summer, 46 of them completed a second questionnaire about their summertime sunbathing behavior The proposed model was successful in predicting both behavior and intention to use sun protection, with 45% of the variance of self-reported sunscreen use and 32% of the variance in intention explained by the TPB. Items designed to measure self-efficacy and perceived control loaded onto different factors and demonstrated discriminant validity. Self-efficacy predicted both intention and behavior (after controlling for all other TPB variables), but perceived behavioral control did not. The authors discuss the implications of the findings for potential interventions to improve sun protection behavior.

Synthesis and aggregation behavior of four-arm star amphiphilic block copolymers in water

We report the first synthesis of amphiphilic four-arm star diblock copolymers consisting of styrene (STY) and acrylic acid (AA) made using reversible addition-fragmentation chain transfer (RAFT; Z group approach with no star-star coupling). The polymerization proceeded in an ideal living manner. The size of the poly(AA(132)-STYm)(4) stars in DMF were small and close to 7 nm, suggesting no star aggregation. Slow addition of water (pH = 6.8) to this mixture resulted in aggregates of 15 stars per micelle with core-shell morphology. Calculations showed that the polyAA blocks were slightly extended with a shell thickness of 15 nm. Treatment of these micelles with piperidine to cleave the block arms from the core resulted in little or no change on micelle size or morphology, but the polyAA shell thickness was close to 29 nm (33 nm is the maximum at full extension) suggesting a release of entropy when the arms are detached from the core molecule. In this work we showed through the use of star amphiphilic polymers that the micelle size, aggregation number, and morphology could be controlled.

The feasibility and outcome of clinic plus Internet delivery of cognitive-behavior therapy for childhood anxiety

Seventy-two clinically anxious children, aged 7 to 14 years, were randomly allocated to clinic-based, cognitive-behavior therapy, the same treatment partially delivered Via the Internet. or a wait-list control (WL). Children in the clinic and clinic-plus-Internet conditions showed significantly greater reductions in anxiety from pre- to posttreatment and were more likely to be free of their anxiety diagnoses, compared with the WL group. Improvements were maintained at 12-month follow-up for both therapy conditions', with minimal difference in outcomes between interventions. The Internet treatment content was highly acceptable to families, with minimal dropout and a high level of therapy compliance.

Perceptions of organizational change: A stress and coping perspective

Few organizational change studies identify the aspects of change that are salient to individuals and that influence well-being. The authors identified three distinct change characteristics: the frequency, impact and planning of change. R. S. Lazarus and S. Folkman's (1984) cognitive phenomenological model of stress and coping was used to propose ways that these change characteristics influence individuals' appraisal of the uncertainty associated with change, and, ultimately, job satisfaction and turnover intentions. Results of a repeated cross-sectional study that collected individuals' perceptions of change one month prior to employee attitudes in consecutive years indicated that while the three change perceptions were moderately to strongly intercorrelated, the change perceptions displayed differential relationships with outcomes. Discussion focuses on the importance of systematically considering individuals' subjective experience of change.

DOSY NMR studies of chemical exchange behavior of poly(2-hydroxyethyl methacrylate)

PFG-NMR was used to study the chemical exchange of linear PHEMA having a range of molecular weights with water in DMSO containing varying quantities of water. The aim was to investigate the use of PFG-NMR to study chemical exchange between a polymer with exchangeable protons and a small fast diffusing molecule to provide insight into the conformation adopted by a polymer in solution. The experimental data were simulated closely for the two-site exchange case using the Bloch equations modified for chemical exchange and diffusion. The exchange rate could be used to detect changes in polymer conformation resulting from changes in the solvent. PHEMA of MW 10 000 showed significant time-dependent changes in exchange rate, resulting from preferential solvation of the OH sites by water, and subsequent conformational changes which altered accessibility of the OH sites to water. This behavior was not observed for larger MW PHEMA, which adopted a stable conformation immediately. Large changes in the exchange rate were not reflected in changes to the hydrodynamic radius, suggesting that a minimal overall change in the chain dimensions occurred. DMSO was found to be a poor solvent for PHEMA, which adopts a compact conformation in DMSO. This work has demonstrated that PFG-NMR is a sensitive method for detecting subtle changes in polymer conformation in polymers with exchangeable protons.