Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial

Objectives To evaluate the effectiveness of integrated motivational interviewing and cognitive behaviour therapy in addition to standard care for patients with psychosis and a co-morbid substance use problem. Design Two-centre, open, rater-blind randomised controlled trial Setting UK Secondary Care Participants 327 patients with clinical diagnoses of schizophrenia, schizophreniform or schizoaffective disorder and DSM-IV diagnoses of drug and/or alcohol dependence or abuse Interventions Participants were randomly allocated to integrated motivational interviewing and cognitive behaviour therapy or standard care. Therapy has two phases. Phase one – “motivation building” – concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two –“Action” – supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year. Main outcomes The primary outcome was death from any cause or admission to hospital in the 12 months after therapy. Secondary outcomes were frequency and amount of substance use (Timeline Followback), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, global assessment of functioning and deliberate self harm, at 12 and 24 months, with additional Timeline Followback assessments at 6 and 18 months. Analysis was by intention-to-treat with robust treatment effect estimates. Results 327 participants were randomised. 326 (99.7%) were assessed on the primary outcome, 246 (75.2%) on main secondary outcomes at 24 months. Regarding the primary outcome, there was no beneficial treatment effect on hospital admissions/ death during follow-up, with 20.2% (33/163) of controls and 23.3% (38/163) of the therapy group deceased or admitted (adjusted odds-ratio 1.16; P= 0.579; 95% confidence interval 0.68 to 1.99). For secondary outcomes there was no treatment effect on frequency of substance use or perceived negative consequences, but a statistically significant effect of therapy on amount used per substance-using day (adjusted odds-ratios: (a) for main substance 1.50; P=0.016; 1.08 to 2.09, (b) all substances 1.48; P=0.017; 1.07 to 2.05). There was a statistically significant treatment effect on readiness to change use at 12 months (adjusted odds-ratio 2.05; P=0.004; 1.26 to 3.31), not maintained at 24 months. There were no treatment effects on assessed clinical outcomes. Conclusions Integrated motivational interviewing and cognitive behaviour therapy for people with psychosis and substance misuse does not improve outcome in terms of hospitalisation, symptom outcomes or functioning. It does result in a reduction in amount of substance use which is maintained over the year’s follow up. Trial registration Current Controlled Trials: ISRCTN14404480

Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance

Social anxiety disorder is one of the most persistent and common of the anxiety disorders, with lifetime prevalence rates in Europe of 6.7% (range 3.9-13.7%).1 It often coexists with depression, substance use disorder, generalised anxiety disorder, panic disorder, and post-traumatic stress disorder.2 It can severely impair a person’s daily functioning by impeding the formation of relationships, reducing quality of life, and negatively affecting performance at work or school. Despite this, and the fact that effective treatments exist, only about half of people with this condition seek treatment, many after waiting 10-15 years.3 Although about 40% of those who develop the condition in childhood or adolescence recover before adulthood,4 for many the disorder persists into adulthood, with the chance of spontaneous recovery then limited compared with other mental health problems. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on recognising, assessing, and treating social anxiety disorder in children, young people, and adults.5

How is the language of medicines use review leaflets symbolising the service?

Introduction The medicines use review (MUR), a new community pharmacy ‘service’, was launched in England and Wales to improve patients’ knowledge and use of medicines through a private, patient–pharmacist appointment. After 18 months, only 30% of pharmacies are providing MURs; at an average of 120 per annum (maximum 400 allowed).1 One reason linked to low delivery is patient recruitment.2 Our aim was to examine how the MUR is symbolised and given meaning via printed patient information, and potential implications. Method The language of 10 MUR patient leaflets, including the NHS booklet,3 and leaflets from multiples and wholesalers was evaluated by discourse analysis. Results and Discussion Before experiencing MURs, patients conceivably ‘categorise’ relationships with pharmacists based on traditional interactions.4 Yet none of the leaflets explicitly describe the MUR as ‘new’ and presuppose patients would become involved in activities outside of their pre-existing relationship with pharmacists such as appointments, self-completion of charts, and pharmacy action plans. The MUR process is described inconsistently, with interchangeable use of formal (‘review meeting‘) and informal (‘friendly’) terminology, the latter presumably to portray an intended ‘negotiation model’ of interaction.5 Assumptions exist about attitudes (‘not understanding’; ‘problems’) that might lead patients to an appointment. However, research has identified a multitude of reasons why patients choose (or not) to consult practitioners,6 and marketing of MURs should also consider other barriers. For example, it may be prudent to remove time limits to avoid implying patients might not be listened to fully, during what is for them an additional practitioner consultation.

In-service and pre-service teachers' opinion on the use of models in teaching chemistry

The presented study examined the opinion of in-service and prospective chemistry teachers about the importance of usage of molecular and crystal models in secondary-level school practice, and investigated some of the reasons for their (non-) usage. The majority of participants stated that the use of models plays an important role in chemistry education and that they would use them more often if the circumstances were more favourable. Many teachers claimed that three-dimensional (3d) models are still not available in sufficient number at their schools; they also pointed to the lack of available computer facilities during chemistry lessons. The research revealed that, besides the inadequate material circumstances, less than one third of participants are able to use simple (freeware) computer programs for drawing molecular structures and their presentation in virtual space; however both groups of teachers expressed the willingness to improve their knowledge in the subject area. The investigation points to several actions which could be undertaken to improve the current situation.

Expectation versus provision in the management and use of urban open space

This paper discusses the implications of the shifting cultural significance of public open space in urban areas. In particular, it focuses on the increasing dysfunction between people's expectations of that space and its actual provision and management. In doing so, the paper applies Lefebvre's ideas of spatiality to the evident paradigm shift from 'public' to 'private' culture, with its associated commodification of previously public space. While developing the construct of paradigm shift, the paper recognises that the former political notions inherent in the provision of public space remain in evidence. So whereas public parks were formerly seen as spaces of confrontation between the 'rationality' of public order as the 'irrationality' of individual leisure pursuits, they are now increasingly seen, particularly 'out of hours', as the domain of the dispossessed, to be defined and policed as 'dangerous'. Where once people were welcomed into public open spaces as a means of 'educating' them in good, acceptable, leisure practices, therefore, they are now increasingly excluded, but for the same ostensible reasons. Building on survey work undertaken in Reading, Berkshire, the paper illustrates how communities can become separated from 'their' space, leaving them with the overriding impression that they have been 'short-changed' in terms of both the provision and the management of urban open space. Rather than the intimacy of local space for local people, therefore, the paper argues that parks have become externalised places, increasingly responding to commercial definitions of culture and what is 'public'. Central urban open spaces are therefore increasingly becoming sites of stratification, signification of a consumer-constructed citizenship and valorisation of public life as a legitimate element of the market surface of town and city centres.

Use of soft heterocyclic N‑donor ligands to separate actinides and lanthanides

The removal of the most long-lived radiotoxic elements from used nuclear fuel, minor actinides, is foreseen as an essential step toward increasing the public acceptance of nuclear energy as a key component of a low-carbon energy future. Once removed from the remaining used fuel, these elements can be used as fuel in their own right in fast reactors or converted into shorter-lived or stable elements by transmutation prior to geological disposal. The SANEX process is proposed to carry out this selective separation by solvent extraction. Recent efforts to develop reagents capable of separating the radioactive minor actinides from lanthanides as part of a future strategy for the management and reprocessing of used nuclear fuel are reviewed. The current strategies for the reprocessing of PUREX raffinate are summarized, and some guiding principles for the design of actinide-selective reagents are defined. The development and testing of different classes of solvent extraction reagent are then summarized, covering some of the earliest ligand designs right through to the current reagents of choice, bis(1,2,4-triazine) ligands. Finally, we summarize research aimed at developing a fundamental understanding of the underlying reasons for the excellent extraction capabilities and high actinide/lanthanide selectivities shown by this class of ligands and our recent efforts to immobilize these reagents onto solid phases.

The use of land-sea warming contrast under climate change to improve impact metrics

A favoured method of assimilating information from state-of-the-art climate models into integrated assessment models of climate impacts is to use the transient climate response (TCR) of the climate models as an input, sometimes accompanied by a pattern matching approach to provide spatial information. More recent approaches to the problem use TCR with another independent piece of climate model output: the land-sea surface warming ratio (φ). In this paper we show why the use of φ in addition to TCR has such utility. Multiple linear regressions of surface temperature change onto TCR and φ in 22 climate models from the CMIP3 multi-model database show that the inclusion of φ explains a much greater fraction of the inter-model variance than using TCR alone. The improvement is particularly pronounced in North America and Eurasia in the boreal summer season, and in the Amazon all year round. The use of φ as the second metric is beneficial for three reasons: firstly it is uncorrelated with TCR in state-of-the-art climate models and can therefore be considered as an independent metric; secondly, because of its projected time-invariance, the magnitude of φ is better constrained than TCR in the immediate future; thirdly, the use of two variables is much simpler than approaches such as pattern scaling from climate models. Finally we show how using the latest estimates of φ from climate models with a mean value of 1.6—as opposed to previously reported values of 1.4—can significantly increase the mean time-integrated discounted damage projections in a state-of-the-art integrated assessment model by about 15 %. When compared to damages calculated without the inclusion of the land-sea warming ratio, this figure rises to 65 %, equivalent to almost 200 trillion dollars over 200 years.

Style and substance: some metal figurines from south-west Britain

A hoard found in Southbroom, Devizes in 1714 contained a group of copper-alloy figurines executed in both classical and local styles and depicting deities belonging to the Graeco-Roman and Gallo-Roman pantheons. The deities in a local style appear to form part of a larger tradition of figurines, predominantly found in the South-West, which are characterised both by a similar artistic style and by the use of Gallo-Roman symbolism and deities, such as the torc, ram-horned snake, carnivorous dog and Sucellus. The unique composition of the hoard in comparison with other hoards of similar date provides insights into the beliefs of Roman Britain.

What are the limitations on the wider therapeutic use of phage?

Bacterial resistance to antibiotics poses a serious health threat. Since research into new antibiotics is not progressing at the same rate as the development of bacterial resistance, widespread calls for alternatives to antibiotics have been made. Phage therapy is an ideal alternative candidate to be investigated. However the success of phage therapy may be hampered by a lack of investment support from large pharmaceutical companies, due to their narrow spectrum of activity in antibiotics, very large costs associated with clinical trials of the variety of phages needed, and regulatory requirements remaining unclear. Intellectual property is difficult to secure for therapeutic phage products for a variety of reasons, and patenting procedures vary widely between the US and the EU. Consequently, companies are more likely to invest in phage products for decontamination or veterinary use, rather than clinical use in humans. Some still raise questions as to the safety of phage therapy overall, suggesting the possibility of cytotoxicity and immunogenicity, depending on the phage preparation and route. On the other hand, with patients dying because of infections untreatable with conventional antibiotics, the question arises as to whether it is ethical not to pursue phage therapy more diligently. A paradigm shift about how phage therapy is perceived is required, as well as more rigorous proof of efficacy in the form of clinical trials of existing medicinal phage products. Phage therapy potential may be fulfilled in the meantime by allowing individual preparations to be used on a named-patient basis, with extensive monitoring and multidisciplinary team input. The National Health Service and academia have a role in carrying out clinical phage research, which would be beneficial to public health, but not necessarily financially rewarding.

Interactions between climate change and land use change on biodiversity: attribution problems, risks, and opportunities

Global change drivers are known to interact in their effects on biodiversity, but much research to date ignores this complexity. As a consequence, there are problems in the attribution of biodiversity change to different drivers and, therefore, our ability to manage habitats and landscapes appropriately. Few studies explicitly acknowledge and account for interactive (i.e., nonadditive) effects of land use and climate change on biodiversity. One reason is that the mechanisms by which drivers interact are poorly understood. We evaluate such mechanisms, including interactions between demographic parameters, evolutionary trade-offs and synergies and threshold effects of population size and patch occupancy on population persistence. Other reasons for the lack of appropriate research are limited data availability and analytical issues in addressing interaction effects. We highlight the influence that attribution errors can have on biodiversity projections and discuss experimental designs and analytical tools suited to this challenge. Finally, we summarize the risks and opportunities provided by the existence of interaction effects. Risks include ineffective conservation management; but opportunities also arise, whereby the negative impacts of climate change on biodiversity can be reduced through appropriate land management as an adaptation measure. We hope that increasing the understanding of key mechanisms underlying interaction effects and discussing appropriate experimental and analytical designs for attribution will help researchers, policy makers, and conservation practitioners to better minimize risks and exploit opportunities provided by land use-climate change interactions.